Over the years, researchers have relied on data from women victims to understand the profile on male perpetrators of intimate partner violence (IPV). IPV studies with male participants in the general population are still emerging in Africa. The contribution of mental ill health to IPV perpetration in the general population that has been documented elsewhere is emergent. Notwithstanding, research with male perpetrators is essential to informing effective prevention programmes and interventions. To contribute to the emerging literature on male perpetrators, we conducted a study to estimate the prevalence and factors associated with IPV perpetration by men in heterosexual relationships. We also modelled pathways to IPV perpetration using data from Zimbabwe.Data were collected through a nationwide survey employing a random and multi-staged sampling method. We recruited and administered a structured questionnaire to 2838 men aged 18 years and above. IPV was measured using an adapted WHO Domestic Violence Questionnaire. Determinants of IPV measured included child abuse, alcohol abuse, post-traumatic stress disorder (PTSD), depressive symptoms, personal gender attitudes and risky sexual behaviours. Multivariate regression modelling was used to assess factors associated with IPV perpetration. Structural equation modelling was used to explore the underlying pathways to recent IPV perpetration.Forty one percent of men had perpetrated IPV in their lifetime and 8.8% percent of men perpetrated IPV in the 12 months before the survey. Older, more educated men, men who binge drank, men who were abused as children or experienced other life traumatic experiences were more likely to perpetrate IPV in lifetime. Depressive symptoms and sexual relationship power (were also associated with lifetime IPV perpetration. IPV perpetration in the last 12 months was associated with binge drinking, PTSD and sexual relationship power. The pathways to IPV perpetration in the last 12 months from child abuse to recent IPV were mediated by comorbid PTSD symptoms, depression binge drinking and sexual relationship power.IPV perpetration was associated with child abuse history, mental ill health, sexual relationship power and personal gender attitudes. Interventions to reduce IPV need to engage men to address gender inequality, mental ill health and reduce alcohol consumption. According to the World Health Organisation, one in every three women (35%) across the globe have experienced some form of physical and or sexual violence perpetrated by their male intimate partner in their lifetime . PopulatUse of violence is more prevalent among men who endorse patriarchal norms supporting male dominance and sexual entitlement is more prevalent among men using violence . Men enaMental ill health, in particular, post-traumatic stress disorder has been shown to increase risk for IPV perpetration , 17. PTSResearch conducted in Zimbabwe with women shows that IPV is a prevalent societal problem –24. HoweThe study was a cross sectional national household survey conducted in 2012 in Zimbabwe. In the survey, participants were selected through a multi-stage random sampling method, using the 2002 Zimbabwe Population Census as the primary sampling frame. At the first sampling stage districts were sampled from all the 10 provinces using a proportionate to size method. At the district level, the primary sampling unit used were the Enumeration Areas (EAs). An enumeration area, also called a census block or census tract, is the smallest geographic unit for which census information is aggregated, compiled and disseminated. An enumeration area is defined by boundaries described on a sketch map or in a geographic information system (GIS) database . Again, The study was conducted in collaboration with and approved by the Government of Zimbabwe’s Ministry of Women Affairs, Gender and Community Development (MWAGCD). Participation in the study was voluntary and prior written informed consent was given by all participants. Interviews were conducted in privacy and participants were assured of confidentiality. To ensure anonymity participants were assigned to random study ID numbers. Unlike studies of women’s experiences of violence where risk for IPV after the interview is high and the need for counselling and support is much more pronounced , the plaData was collected through self-administered questionnaires loaded onto a personal digital assistant (PDA). Men aged 18 or older normally resident in the sampled household were recruited and interviewed by trained male researchers using structured questionnaires in a language chosen by the participant from English, Shona or Ndebele.. IPV experience in the past 12 months was measured using a follow-up question to each set of sub-scale questions for emotional, sexual and physical IPV as follows: “Have any of these things happened in the past 12 months?” The composite lifetime IPV variable was derived from combining the physical and/or sexual IPV and emotional IPV subscale items and if a man had done any of the acts towards a partner. A similar approach was used for the IPV past 12 months variable.The primary outcome of interest was lifetime sexual or physical IPV perpetration and these were measured using an adapted and pretested version of the WHO Multi-Country Study on Women’s Health and Domestic Violence: Core Questionnaire and WHO Instrument – Version 9 designed for use in developing countries . Table 1(Table 1). Responses to items were Never . R. R(TableTable ))  or No  to measure attitudes toward gender norms in intimate relationships and differing social expectations for men and women Table  32]. Re. Re32]. We used an adaptation of the Sexual Relationship Power Scale (SRPS) to measure power within sexual relationships. The scale consisted of relationship control items that predict sexual and physical violence, condom use and partner infidelity Table  33]. Re. Re33]. n = 436). All data analyses were done using Stata version 13 considering the survey’s multi-stage sample design. We used cross tabulations to describe the prevalence of lifetime and past 12 months IPV perpetration against the different sociodemographic variables, binge drinking, and sexual partners (Table 2). For the continuous variables - Child abuse, CESD, PTSD, Life events, GEM and SRPS Scores, we used t-tests to compare the means across perpetrator vs non-perpetrator groups for both the lifetime IPV and past 12 months IPV (Table ).For this secondary analyses we excluded men who had never been in a heterosexual intimate relationship n = 46. All dap-value less than 0.2 in bivariate analyses into regression models. We controlled for the effect of sociodemographic variables  in models. We then used a stepwise backward elimination approach to eliminate non-significant associations until final models were arrived at that were parsimonious (Table ).To test for factors associated with lifetime and past 12 months IPV, we built logistic regression models. We included characteristics that had a us Table .Table 4FFurther to the logistic regression modelling, we employed Structural Equation Modelling (SEM) with maximum likelihood estimation to investigate the underlying pathways of factors associated with recent/or 12 months IPV perpetration. Our a priori model was that there were significant inter-relationships between variables. Child abuse could be associated with life traumatic events, mental ill health, gender scales and IPV perpetration. Gender scales could predict IPV perpetration. Mental ill health symptoms could be comorbid and predict IPV perpetration. We fitted an SEM model based on known assumptions from the literature  and theThe sample comprised 2838 men who had been in heterosexual intimate relationships: 41% perpetrated IPV in lifetime and 8.8% perpetrated IPV in the 12 months before the survey. One in ten men had a score of 30 or above on the PTSD scale, 20.5% had a CESD score of 16 or more, 88.7% had experienced some form of child abuse.p = 0.0005). There was however no significant difference in IPV perpetration in past 12 months by age (p = 0.147). There was no significant difference in perpetration of lifetime or past 12 months IPV by men’s highest educational attainment. More men who were employed in the last 12 months perpetrated violence than men who were not employed in the same period (p = 0.0007). A higher proportion of men who worked to earn income in the past 12 months perpetrated IPV in a similar period. A higher proportion of men who binge drank perpetrated IPV in lifetime (p = 0.0002) and in the past 12 months (p < 0.0001) than those who did not binge drink. A higher proportion of men who had 2 or more partners in the past 12 months perpetrated IPV in the same period than those who had less than two sexual partners (p = 0.0119).Table Table (Table ). Older men were more likely to perpetrate lifetime IPV compared to the 18–29 year olds. The risk for lifetime IPV perpetration increased with child trauma, traumatic life events, depression and PTSD symptom scores. Men who binge drank were 89% more likely to perpetrate IPV in lifetime compared to men who did not binge drink. Higher scores on the SRPS scales were protective of lifetime IPV perpetration.Table Table a. Older (Table ). Men who binge drank were 81% more likely to perpetrate IPV compared to the men who did not. Risk for IPV perpetration in past 12 months increased with PTSD symptoms. Higher scores on the SRPS scale were protective of past 12 months IPV perpetration (Table ).Factors associated with IPV in past 12 months were binge drinking, PTSD and sexual relationship power Table b. Men whon Table b.p value = < 0.0001).Figure The study aimed to investigate the factors associated with men’s use of violence against intimate partners. Factors associated with lifetime perpetration included child abuse, high gender inequity attitudes, binge drinking, life traumatic events, depressive symptoms and sexual relationship power. Factors associated with recent IPV perpetration included binge drinking, PTSD symptoms and less sexual relationship power. Path modelling of variables showed that child abuse had direct effects on PTSD, depression, gender attitudes and sexual relationship power. Sexual relationship power, binge drinking, PTSD and CESD had direct effects on IPV in past 12 months.The findings show the contribution of child abuse to IPV perpetration in a context where corporal punishment at home and in school institutions is legalized through Article 241 of the Criminal Law (Codification and Reform) Act 2004 and the Article 7 of the Children’s Act 1972 . Child aChild abuse also had effects on gender attitudes and sexual relationship power. This is consistent with literature showing that men who were  abused in childhood are more likely to have witnessed parental violence and have been socialized into gender inequitable norms leading to their  use violence in their intimate  relationships . These fMental ill health among men was also shown to be a determinant of violence perpetration. Consistent with other research showing PTSD as a risk factor for IPV  perpetration, , 18, 41 Notwithstanding, the data showed comorbidities between binge drinking and depression and that binge drinking fully-mediated the relationship with violence perpetration. Further investigations are necessary to understand these relationships because they provide an opportunity for intervening to reduce violence. The association of binge drinking with IPV perpetration can be explained by the distortion of perceptions of cues and lowering of inhibitions which lead to aggression in a relationship . ConsideThe data also shows that inequitable gender norms and behaviours associated with IPV are a key driver of violence perpetration. Gender norms are the result of socialization of individuals based on social expectations for appropriate behaviours of males and females. Society defines context specific models of manhood and these are passed onto boys and men through cultural processes. When norms are inequitable they negatively affect relationships with women and are often associated with partner violence . SexualiInequitable gender attitudes were also associated with sexual relationship power. The SRPS was developed to measure women’s ability to negotiate safer sex practices and HIV risk as it relates to gender-based imbalances in the relationship . The assThe relationship between loss of economic power and perpetration of violence has been discussed in many settings . This exThere are several limitations to the study. The cross-sectional design limits the study in establishing temporality but the path analysis assists us to know how the factors are ordered and the directions in which variables are linked. We cannot conclude on the relationship between depression and IPV as there may be other factors associated with depression that were not measured in this study, for example, economic stressors. The observed relationships in this study are those that can be concluded based on the included variables only. The paper is based on men’s self-report data which may have been affected by response bias such as unwillingness to disclose socially undesirable behaviors or characteristics. Nevertheless, the study methodology has its strengths which include having a nationwide coverage and a community based sample with sufficient power to generalize the findings.The study found high levels of lifetime male perpetration of intimate partner violence. Lifetime perpetration of IPV was associated with child abuse, high gender equity attitudes, binge drinking, life traumatic events, depressive symptoms and sexual relationship power. Factors associated with recent IPV perpetration were binge drinking, PTSD symptoms and less sexual relationship power. The causal pathway analysis found experiences of child abuse having a direct effect on PTSD, depressive symptoms, gender attitudes and sexual relationship power. PTSD, depressive symptoms, binge drinking and sexual relationship power had a direct effect on IPV in past 12 months.The public health implications of these findings are that primary prevention of IPV perpetration must focus on reducing child abuse by addressing negative parenting practices. Secondary prevention needs to address changing gender norms, promoting responsible behaviours, gender equitable masculinities as well as addressing mental ill health symptoms and alcohol abuse.


This study investigates the association between intimate partner violence (IPV) against women and its impact on child morbidity in the south Asian region.The analysis uses logistic regression models with cross sectional nationally representative data from three countries - Bangladesh, India and Nepal. The data have been pooled from ‘Demographic and Health Surveys’ (DHS) of Bangladesh, Nepal and ‘National Family and Health Survey’ (NFHS) of India.adj 1.57; 95 % CI 1.48–1.67), fever  and diarrhea .The study revealed that after controlling for potential confounders, children of mothers experiencing physical violence, sexual violence or both were more likely to have Acute Respiratory Infection (ARI) (ORThe results highlight that IPV can influence childhood morbidity and support the need to address IPV with a greater focus within current child nutrition and health programs and policies. During the last decade several studies investigated the impact of intimate partner violence (IPV) on children’s health. A recent study by World Health Organization (WHO) shows that the global prevalence of physical and/or sexual intimate partner violence among all ever-partnered women was 30.0 % . The estEvidence is available on negative consequences of IPV for women’s health and well-being . SeveralSignificant attention has also been dedicated to the potential negative role of IPV on the health and survival of infants. Some population based studies have reported considerable adverse effects of IPV upon gestational and birth outcomes . This alStudies on the association between IPV and childhood mortality are much more limited. Most of such studies come from developed countries. Scanty literature on this topic in the developing world includes some studies from India and one study from Bangladesh. Several studies from north India suggested significant association between lifetime IPV and infant mortality risks , 19, 23.Studies in Bangladesh convincingly showed that children of women exposed to IPV have greater exposure to potentially dangerous conditions like diarrhea and Acute Respiratory Infection (ARI) , 36. ImpThe current study builds upon the existing literature and explores association between IPV and childhood morbidity expanding the study beyond a single country to include three neighboring countries in South Asia, i.e., Bangladesh, India and Nepal.The study uses three datasets – BangladThis secondary analysis includes a total of 40,394 women from India, Bangladesh and Nepal. The women selected for the violence module had at least one child under the age of 5 years during the survey. We included all the children under the age of 5 years in this sample. Therefore a total number of 58,725 children of these women were included in the study.The original survey was administrated in accordance with the WHO ethical and safety guidelines for research on IPV. The institution review board of ICF Macro , an advisory, implementation, and evaluation services firm providing research-based solutions to U.S. federal government agencies in health and other areas. Reviewed and approved the surveys used in the study. The interviewers received special training to implement this module. The training focused on how to ask sensitive questions, ensure privacy, and build rapport between interviewer and respondent. Verbal Informed consent was also obtained from the respondents. Details of the informed consent statement can be found in the appendix section of the respective reports , 27, 29.This study considers IPV as the main exposure variable while child morbidity as the outcome of interest.i.Has your husband pushed, shook or threw something?ii.Has your husband slapped you?iii.Has your husband twisted your arm or pulled your hair?iv.Has your husband punched with fist or something harmful?v.Has your husband kicked you, dragged you or beaten you up?vi.Have you been threatened by a weapon or had a weapon used against you by your husband? Has your husband been choked you or burn you on purpose?vii.Have you been physically forced to have sex or otherwise sexually abused by your husband?Women were asked the following questions about their experience of IPV involving their husbands over the past 12 months.A new dummy IPV variable was created based on the answer to the above questions. A positive response to any one of the first six questions was treated as indicative of physical IPV victimization and was coded as “1” and if none of the responses was positive, exposure to physical violence was coded as “0”. A similar strategy was followed for deriving a variable indicating exposure or non-exposure to sexual IPV. Then two more variables were created to indicate exposure to any IPV or both IPV.Women were asked whether their child had been ill with fever, diarrhea, or a cough accompanied by short, rapid breathing in the 2 weeks prior to the surveys. Acute Respiratory Infection (ARI) was defined as the presence of cough, along with short, rapid breathing. Binary variables for Diarrhea, ARI and Fever were created which indicated the presence of each of these outcomes among the children in the past 2 weeks prior the survey. For these cases, “0” indicated absence of the symptoms while “1” indicated presence of the same.The study controlled for well established correlates of child morbidity such as age, religion, education, living standard, employment status and areas of residence , 27, 29.Respondent’s age was classified into 5 groups. The respondents were asked if they attended any educational institution and if yes then the highest level completed  was asked. We used the information to classify education of the mother into the following categories: .Respondents were asked about the main source of drinking water for their household and presented with options like piped water, tube well or borehole, dug well, spring water, surface water etc. The responses were grouped into three major categories: Tube well or borehole, piped water and other sources. Women were asked about the toilet facility and the responses were classified in the groups of pit latrine, flush and no facility. Cooking fuel of the household was classified into: electricity, gas, kerosene, wood/coal and others.We used the DHS wealth index calculated as follows: each asset was assigned a weight (factor score) generated through principal component analysis, and the resulting asset scores were standardized in relation to a normal distribution with a mean of zero and standard deviation of one. Each household was then assigned a score for each asset, and the scores were summed for each household; individuals were ranked according to the total score of the household in which they resided. The sample was then divided into quintiles from one (lowest) to five (highest).We calculated descriptive statistics for socio-demographic and morbidity characteristics for our selected sample individuals. The relationhip between morbidity and selected demographic and socio-economic factors were examined first using chi-square test. Then we used logistic regression models for exploring the relationship between IPV and different child morbidity outcomes. After this step we ran multiple logistic regression analysis. We calculated the adjusted odds ratio to measure the strength of associations. SPSS version 17 was used for the analysis.Background characteristics of the women and their children are presented in Table p < 0.001).In Table Table The results show that Maternal experience of physical IPV increased the likelihood of child fever by 46 % , sexual IPV by 67 % , and both physical and sexual IPV by 64 % .Maternal exposure to physical IPV increased the risks of diarrhea of the child by 55 % , sexual IPV by 79 %  and both physical and sexual IPV by 66 % .Maternal experience of physical IPV increased the likelihood of child’s ARI by 53 %  sexual IPV by 72 %  and both physical and sexual IPV by 76 % .Poor mental health of the mother: Women who experience IPV tend to have higher level of psychological stress , 26 whicLack of empowerment: Intimate partner violence is often used as a tool for controlling women . Thus IPPoor physical condition of the mother: In case of extreme IPV often the victims become physically unfit to give proper care to their children.The central aim of this study was to investigate the association between Intimate Partner Violence against women and child morbidity in South. The results of the study provide evidence of an association between IPV and child morbidity in these three countries of South Asia. The results are in line with previous findings , 35, 36.Besides, the children who witness IPV themselves tend to experience psychological stress; which in turn result in poor physiological conditions making the children vulnerable to morbidity , 11, 22.The cross sectional study design represents a limitation of this study. Though there may be some concern regarding the temporal ordering of IPV and child morbidity in cross sectional studies, previous research shows that IPV in this subcontinent is a relatively stable phenomenon that has its root in patriarchal structures and community norms of high acceptability of wife beating .Another limitation of the study is that both the outcome and the exposure variables are measured through self reports. Although in the DHS much care and preparation is taken into the design and execution of the interviews to create a safe atmosphere in which respondents would feel comfortable discussing the IPV, high stake in disclosure may always cause under reporting.The study shows that IPV negatively affects child’s health not only in individual countries, but also in the South Asia region. The children of an abused mother are more likely to experience diseases like fever, diarrhea and ARI compared to the children of non-abused mothers. IPV should be considered as a major health problem affecting not only women, but also their children in South Asia. Although it seems IPV is most strongly associated with socioeconomic demographic and contextual disadvantages, incidents of IPV among socially marginalized groups may aggravate the negative effects of cumulative disadvantages of poor child health outcomes. The health sector in these countries needs to take action to eliminate IPV for improving child health. Future studies should investigate the influence of potential mechanisms mediating the association of IPV and child morbidity.


A combination of intimate partner violence (IPV) and depression is a common feature of the perinatal period globally. Understanding this association can provide indications of how IPV can be addressed or prevented during pregnancy. This paper aims to determine the prevalence and correlates of IPV among pregnant low-income women with depressive symptoms in Khayelitsha, South Africa, and changes in IPV reports during the course of the perinatal period.This study is a secondary analysis of data collected as part of a randomised controlled trial testing a psychosocial intervention for antenatal depression. IPV, socio-demographic measures, depression and other mental health measures were collected at recruitment , 8 months gestation, and 3 and 12 months postpartum. IPV was defined as a sexual or physical violence perpetrated by the participant's partner in the past 3 months. Descriptive statistics are reported.Of 425 recruited depressed participants, 59 (13.9%) reported IPV at baseline, with physical IPV being the most frequently reported (69.5%). Reported IPV was associated with greater emotional distress, potentially higher food insecurity and higher rates of alcohol abuse. There were clear longitudinal trends in reported IPV with the majority of women no longer reporting IPV postpartum. However, some women reported IPV at later assessment points after not reporting IPV at baseline.There is a strong association between IPV and depression in pregnancy. IPV reports remit over time for the women in this study, although the reason for this reduction is not clear and requires further investigation. If participants reported IPV, they were encouraged to report it to their local police station. If a woman reported suicidal ideation or behaviour, she was referred to the clinic psychiatric nurse for further assessment and management.The full sample enrolled in the AFFIRM-SA trial , 8 months gestation, 3 months postpartum and 12 months postpartum. The measures collected at all assessment time points are described in the AFFIRM-SA RCT protocol  the victim of physical violence in the last 3 months ; and (2) the victim of sexual violence in the last 3 months. If participants answered affirmatively to one or both questions, they were asked by whom. Physical or sexual IPV was defined as responding yes to the first or second question, respectively, and specifying the violence was perpetrated by the partner. As stated earlier, we did not include verbal abuse as it usually coincides with either physical or sexual abuse (Mitchell https://www.mobenzi.com), which minimised missing data for completed assessments. Attrition at follow-up ranged between 21 and 29%, and was highest at the 8-month gestation assessment. The main reasons for missed assessments were because of having given birth (for 8-month gestation assessment), not being contactable or refusal to continue their participation. Participants were suspended from the trial if they had a miscarriage or stillbirth, but were offered continued counselling outside of the trial intervention.Data collected as part of the assessments were captured on an android mobile device system  results of the RCT suggest that the intervention and control arms showed little difference in depressive symptoms at 3 months postpartum, the primary outcome measure. For this reason, the two arms were combined and analysed as one group for the purpose of this study. No imputation was conducted to address missing assessments.U tests were performed to assess continuous correlates of IPV at baseline and continuous infant and maternal outcomes at 3 months postpartum. Correlates of the incidence of IPV later in pregnancy or postpartum v. those who never reported IPV were investigated using the Kruskal–Wallis test.Given the small sample of women reporting different forms of IPV at baseline, physical and sexual IPV were analysed together and only descriptive analyses and non-parametric univariate analyses were conducted. The Fisher's exact test was used to assess baseline categorical variables in relation to IPV at baseline or the incidence of IPV later in pregnancy or postpartum. The same test was used to compare categorical birth, infant and maternal outcomes at 3 months postpartum between participants reporting IPV during pregnancy and those who did not. Mann–Whitney The child and maternal outcomes assessed at 12 months postnatal assessment were not included in these analyses, since we could not control for potential confounders.n = 235, 55.3%) with a mean age of 27.3 years (s.d. = 5.72). Nearly all women reported having a partner , but only a third actually lived with their partner (34.8%). Approximately 40% of the sample had finished secondary education, and nearly half were employed at the time of recruitment . Participants in the study all had symptoms of depression based on the EPDS (as per the inclusion criteria). However, 41.4% were diagnosed with clinical depression on the MINI, and 17.4% were considered at high risk of suicide.Out of the 425 participants, 59 participants (13.9%) reported having experienced physical and/or sexual IPV in the past 3 months at baseline: 52 (12.2%) reported physical IPV and 18 (4.2%) reported sexual IPV. Altogether, 11 (2.6%) participants reported experiencing both forms of IPV. 2 = 6.20, p < 0.05). There were no other demographic differences between the two groups, though a marginally greater proportion of those who reported IPV had a lower education level and greater food insecurity.U = −2.95, p < 0.05), EPDS  and the AUDIT , compared with participants who did not report IPV . Finally, as measured by the MINI, nearly twice as many participants who reported IPV received a diagnosis of depression  and were at a significantly high risk of suicide , compared with participants not experiencing IPV . The two groups did not differ on levels of impaired functioning or on their perceived level of social support.Clinically, however, participants who experienced IPV at baseline had significantly worse symptoms (i.e. higher scores) on the HAM-D . Of these, one reported no longer being with a partner at the 8-month gestation assessment, and a further 10 reported no longer being with a partner at the time of the 3-month postpartum assessment. This suggests that the reported IPV subsided before the person separated from their partner. Over a quarter of participants , however, continued to experience IPV during the postpartum period. Of those who did not experience IPV at baseline , 12.8% (n = 47) went on to report IPV in later assessments, either later in pregnancy  or in the postpartum period .Of participants who reported IPV at baseline, the majority no longer reported experiencing IPV at 3 months post-partum . Results suggest that a greater proportion of participants who lived with their partners at baseline reported IPV starting at the end of pregnancy (8.4%), compared with those who did not live with their partner (1.6%) . A greater proportion of participants who were employed at baseline reported the incidence of IPV at the end of pregnancy (6.2%), rather than in the postnatal period (5.2%) . The opposite was true for those who were unemployed at baseline, with 2.0% reporting the incidence of IPV late in pregnancy, and 11.2% postpartum . Age was also marginally associated with the incidence of IPV: older participants (aged 31 years or more) were more likely to experience IPV later in pregnancy. None of the younger participants (aged 18–21) reported IPV before birth, but the incidence of IPV postpartum was highest in this younger age group.H = 12.34, p < 0.01), compared with the other two groups . A similar, but marginal trend was found for HAM-D scores: participants who reported IPV postpartum had marginally greater baseline HAM-D scores compared with those who never reported IPV, or those who reported the incidence of IPV later in pregnancy. Finally, a marginally greater proportion of women diagnosed with depression at baseline reported the incidence of IPV, both before and after birth , compared with those who were not diagnosed with depression .Participants who reported postnatal incidence of IPV had significantly greater AUDIT scores at baseline  and those who did not . No diffU = −2.84, p < 0.05) and the EPDS , compared with those who never reported IPV .No differences were found between the two groups, either in terms of anthropometric characteristics, breastfeeding length or health problems. Differences were found in relation to maternal clinical symptoms, however. Participants who reported IPV during pregnancy had greater depressive symptoms at 3 months postpartum, as measured by the HAM-D  of the sample of pregnant women with depressive symptoms, with the majority of these being physical IPV. Limited comparisons can be made between the prevalence of IPV reported in this study to that of other studies, as most studies investigated trends among all pregnant women. However, there is evidence that pregnant women who are depressed report higher rates of IPV than those not depressed when screening all pregnant women. Connelly et al.  range from 5 to 20% in low- and middle-income contexts  predictors of IPV later in pregnancy and postpartum, and IPV during pregnancy predicted high depressive symptoms at 3 months postpartum. However, the small sample and non-parametric analyses mean that we need to be cautious about these findings, as the small sample size did not allow for multivariate analyses, and so we could not control for any confounders.v. no IPV during pregnancy. This could be due to the small sample and the lack of variation across these measures in the overall sample. It could also be explained in part by the nature of the cohort, in that all participants were already compromised because of their depressive symptoms, which themselves are associated with adverse birth outcomes  do not differ much in terms of demographic characteristics. They do, however, differ in terms of depressive symptoms and alcohol use behaviours: participants who report IPV starting postpartum had greater depressive and alcohol abuse symptoms at baseline than participants who report IPV during the course of pregnancy. The reasons for this are not clear and could be elucidated through further research more specifically targeted at IPV in the perinatal period and specifically following up women postpartum.The two IPV groups . This suggests that IPV may have been present before worsening of depressive symptoms.et al.The profile of the participants reporting any IPV in our study reflect a high degree of vulnerability, with greater emotional distress, a tendency towards higher food insecurity and higher rates of alcohol abuse, compared with women without IPV. These concur with profiles reported in other studies, with food insecurity and unemployment being common aspects associated with the reports of IPV  and by the Western Cape Department of Health and health facilities involved in the trial. Each participant signed an informed consent form before being recruited into the study.


Intimate partner violence (IPV) experienced by pregnant and post-partum women has negative health effects for women, as well as the foetus, and the new-born child. In this study we sought to assess the prevalence and factors associated with recent IPV amongst post-partum women in one clinic in eThekwini Municipality, South Africa, and explore the relationship between IPV, depression and functional limitations/disabilities. Past 12 month IPV-victimisation was 10.55%. Logistic regression modelled relationships between IPV, functional limitations, depressive symptoms, socio-economic measures, and sexual relationship power. In logistic regression models, overall severity of functional limitations were not associated with IPV-victimisation when treated as a continuous overall score. In this model relationship power  and depressive symptoms  were significant. When the different functional limitations were separated out in a second model, significant factors were relationship power , depressive symptoms  and mobility limitations . The study emphasises that not all functional limitations are associated with IPV-experience, that depression and disability while overlapping can also be considered different drivers of vulnerability, and that women’s experience of IPV is not dependent on pregnancy specific factors, but rather wider social factors that all women experience. IPV during pregnancy and in the post-partum period is relatively common globally . The preExperiencing IPV is not only a human rights violation, but also has profound health and social consequences for women . Women wExperiencing IPV during pregnancy and in the post-partum period has not only serious health and social consequences for women, but also negative implications for the developing foetus and the new-born child, such as higher levels of pre-term birth and lower birth weight compared to women not exposed to violence during pregnancy .Research investigating the factors driving women’s experiences of IPV have been linked to gender inequalities, whereby women have less social, economic and political power than men and this social and economic dependency places them at risk of IPV-victimisation , 12. ForWomen may experience additional vulnerabilities to IPV-victimisation during pregnancy. One risk factor is whether the pregnancy was unintended . In addiAlthough depression is a potential consequence of IPV it has also been identified as a risk factor for experiencing IPV . Recent In addition, recent research also suggest a strong association between IPV and disability, a factor that has not been widely investigated in mainstream IPV research. A global systematic review on violence among people with disabilities highlighted that this population are more likely to experience IPV than people without disabilities , 20. ThiAdditionally there may be a complex relationship between disability and depression. Depression is a health condition that can lead to disability through limitations in activities and participation in society . Work amIn this paper, we sought 1) to understand the prevalence and factors associated with IPV amongst post-partum women in one clinic in eThekwini Municipality, South Africa. And 2) to understand the associations between IPV and, depression, and disability in this population amongst women experiencing IPV and those not.This was a cross-sectional study, conducted in one public sector primary healthcare facility serving a large, urban informal settlement in eThekwini Municipality, South Africa. The community is characterized by dense informal dwellings, high levels of poverty, lack of access to formal sanitation and water, and generalized high levels of violence. In addition, 41% of women attending antenatal care in eThekwini Municipality, are estimated to be living with HIV .All participants were aged 18 or older and were biological mothers of infants six weeks old or younger. Women were consecutively recruited from January to March 2015. Within the clinic all women were screened (if they consented) while waiting in a queue to be seen by the health provider. If women agreed and met the eligibility criteria, they were directed to be interviewed by research assistants after their clinic visit. All enrolled participants were given ZAR100 as remuneration for their time and transport. All participants provided written informed consent.Ethical clearance for the study was obtained from the Biomedical Research Ethics Committee at the University of KwaZulu-Natal (BE397/13), Boston Children’s Hospital Ethics Review Board (IRB-P00010899), and the University of the Witwatersrand Human Research Ethics Committee (M140426). Additional approvals were obtained from the Provincial Health Research Committee in the KwaZulu-Natal Provincial Department of Health, the eThekwini District Department of Health, and the health facility where the research was conducted.Face-to-face structured interviews using a quantitative questionnaire were conducted by female research assistants in a private space at the clinic. All interviews were conducted in isiZulu. Data were collected and entered by research staff on handheld computer tablet operating Open Data Kit (ODK) Collect. Procedures to promote data quality included skip patterns, range limits and logical checks built into the ODK Collect entry programme, as well as data validation. Participants could choose not to answer questions.Structured questionnaires were used to collect data. Sociodemographic questions included age and education level (including none and post-secondary). HIV-status was based on self-report, with possible responses being: HIV-positive, HIV-negative, refuse to answer, or not known. In the analysis, we recoded refused to answer and not known together as a combined category.Socio-economic status was assessed using a range of measures. Household food insecurity was assessed using the Household Food Insecurity Access Scale (HFIAS) . The HFIFor assets, participants were asked whether households had 15 specific items including a television, hot running water and an electric stove. These items were combined into a scale using Principal Components Analysis of the covariance matrix to create a single score measuring household wealth. This approach is common within economic literature .The primary outcome for this analysis was women’s recent physical and/or sexual IPV victimisation using a scale based on the World Health Organization’s (WHO) violence against women survey and modified for South Africa , 30. PhyDisability was understood as related to functional limitations and assessed using the 12 item WHODAS 2.0 (α = 0.81) . The WHOPower in a sexual relationship was measured with fourteen items of the Sexual Relationship Power Scale (SRPS) (α = 0.86) . QuestioDepressive symptoms were assessed using the PHQ-9 scale (α = 0.75), which has been previously validated in South Africa , 33. NinAnalyses were conducted in STATA/IC14 with individuals as the unit of analysis. Descriptive statistics were first calculated comparing those who had not experienced recent IPV with those who had on all variables. We then undertook unadjusted logistic regression to estimate odds ratios and p-values for each secondary variable.Due to small sample size, in the logistic regression models we entered variables that were significant in the unadjusted analyses at p<0.2. We controlled for age group and educational level. Manual backwards elimination was used to remove variables not making a statistically significant contribution to the model. The backward method is recommended because it is less likely to incur Type II error . We contTo understand intersections between IPV and disability, we built three separate logistic regression models. In model one, we treated WHODAS 2.0 as a continuous reweighted variable  to assesBetween January 2015 and March 2015, women presenting for post-natal care at the clinic were consecutively recruited and screened for eligibility. Of 346 women approached, all agreed to be screened, of whom 310 (89.6%) met study eligibility criteria. Of those eligible, 25 (8.1%) refused to participate in the study citing lack of time. An additional 10, who initially agreed to participate, did not complete the interviews for a variety of reasons including being referred to another clinic during the study visit and thus not completing interviews, and lack of time.In total, 275 mothers were recruited into the study, mean age 26.3 years (95%CI 25.7–27.0) . The majPrevalence of past 12-month sexual and/or physical IPV was 10.55% (n = 29). In unadjusted analyses , having Functional limitations/disability were also associated with a greater likelihood of IPV victimisation. With the reweighted WHODAS 2.0 scale, women reporting higher severity of functional limitations reported more IPV victimisation . Women reporting challenges around self-care , mobility challenges , getting along with people , challenges around general life activities  and participation in social activities  all reported increased odds of IPV-victimisation.and depressive symptoms also reported functional limitations, only 1% (n = 2) did not report this. This suggests a high degree of overlap between depressive symptoms and potential disability in this population.To understand the potentially complex relationship between IPV, depressive symptoms, and disability we examined data using two methods. Firstly, our descriptive analysis in the Venn Diagram  highlighIn model 1 , where fIn model 2  functionIn model 3  an interRecent IPV in postpartum women in this sample was relatively high at 10.55%. This is higher than a study by Groves, McNaughton-Reyes  in SouthThere appears to be a complex relationship between IPV and functional limitations/disability. From other research it is known that people with disabilities are substantially more likely to experience violence than people without disabilities . The meaThese results suggest that not all forms of functional limitations have the same risk of increasing women’s experiences of IPV in this sample. In the second model, which focused on categorising women into different forms of functional limitations, only those with mobility limitations experienced higher IPV vulnerability in the final model. As such, it is only women with the specific mobility limitations who experienced greater likelihood of IPV-victimisation. This relationship is likely to be bi-directional, with women who experience IPV having reduced mobility due to physical harm, and women with reduced mobility being more vulnerable to IPV victimisation. This has been seen in other studies, but the direction of causality is unclear . In thisIn model three there was no significant interaction effect between depression and mobility limitations, which may be explained with the small sample size. Despite the lack of interaction effect and, even though we don't yet understand the direction of these associations, our study provides a clear indication that depression and functional limitations should not be considered in isolation, but that the combination of both may create a further risk for IPV. Depression can be associated with certain life experiences that are more common among people with disabilities, who face many unique problems and challenges, which may place them at increased risk for depression .As with other studies, women’s power in sexual relationships was an important factor shaping IPV-vulnerability, whereby those with more power in relationships, experienced less violence in both models. Studies have highlighted the central role of women’s power in relationships as being protective of experiencing IPV , 11, 15.Finally, in both models women reporting higher levels of depressive symptoms had greater likelihood of IPV-victimisation. The relationship between depression and IPV is likely bi-directional with depression as an outcome, and a ‘cause’, of IPV . For femThe study showed no pregnancy ‘specific’ factors linked to IPV-victimisation. Other research has highlighted that women who have unintended pregnancies are more likely to experience IPV , althougThis study has several limitations. First, the relatively small sample size and exploratory nature of the analysis meant that associations might have been too small to identify. In addition, as it was a clinic-based sample, it likely under-sampled those with the most severe forms of disability and depression, and cannot be thought of as generalizable to the wider population, although the relationships may still hold true. Finally, as the study is cross-sectional, the directionality of the relationships between IPV, the onset of disability, and depression cannot be established.Few studies have explored the relationship between IPV, depression and disability. This analysis highlights the complex relationship between these issues and raises questions about how to conceptualise and analyse these relationships. First, it showed that while there was a close overlap between depression and disability in the study, they also appeared to be distinct in their relationship to IPV-victimisation. Second, it highlighted that not all forms of disability appeared to place women at risk of IPV-victimisation, but rather it was specific forms of disability, in this case mobility limitations that were associated to women’s vulnerability. As such, research needs to follow women over time to understand the interaction of depression and disability. Analysis also needs to disaggregate effects via disability types to understand when and how different functional limitations may impact on IPV-victimisation.The findings emphasise several important approaches for developing interventions to prevent IPV-victimisation. It is important to recognise that pregnant women are vulnerable to IPV because of wider social factors, rather than pregnancy specific factors alone. Thus, strengthening women’s power in relationships, and working to reduce depressive symptoms, should be an important component of interventions. There is a substantive and growing body of research emphasising the importance of women’s social empowerment  and thesThe study also highlights a strong relationship between certain forms of disability and the risk of IPV-victimisation. Given the lack of effective interventions to reduce IPV amongst women living with disabilities, adapting current evidence-based approaches so that they also include women with more severe disabilities remains a critical challenge to ensure that all women can live free from violence .S1 FigMean for SRPS data for participants with no missing data, and for participants with missing data.(TIF)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S2 FileIndividual level participant data used in analysis.(XLS)Click here for additional data file.


Intimate partner violence (IPV) during pregnancy increases adverse pregnancy outcomes. Knowledge of societal, community, family and individual related factors associated with IPV in pregnancy is limited in Ethiopia. Our study examined these factors in an Ethiopian context.A cross sectional study was conducted among pregnant women attending antenatal care at governmental health institutions, using a consecutive probability sampling strategy. A total of 720 pregnant women were interviewed by five trained nurses or midwives, using a standardized and /pretested survey questionnaire. Bivariate and multivariate logistic regression analyses were applied to assess factors contributing to IPV. We used Akaike’s information criteria, to identify the model that best describes the factors influencing IPV in pregnancy.Among the women interviewed, physical IPV was reported by 35.6%, and lifetime emotional or physical abuse by 81.0%. Perceiving violence as a means to settle interpersonal conflicts, presence of supportive attitudes of wife beating in the society, regarding violence as an expression of masculinity, and presence of strict gender role differences in the society, were all positively associated to IPV in pregnancy. The presence of groups legitimizing men’s violence in the community, feeling isolated, having no social support for victims, and presence of high unemployment, were the perceived community related factors positively associated with IPV in pregnancy.IPV in pregnancy is very prevalent in Ethiopia and is associated with multiple social ecologic factors. Reduction of IPV in pregnancy calls for cross sectorial efforts from stakeholders at different levels. It is important to conceptualize violence as a multifaceted phenomenon grounded in the interplay across societal, community, family, and individual levels. There is a lack of studies that simultaneously examine societal, community, family, and individual related factors contributing to IPV in pregnancy in Africa and in Ethiopia in particular.Intimate partner violence (IPV), is an important global public health and human rights issue, with significant health and socioeconomic development consequences . ViolencA healthy pregnancy is required for favourable maternal and child health outcomes. Pregnancies affected by IPV are reported to have an increased incidence of low maternal weight gain, anaemia, infection, first/second trimester bleeding, late entry into antenatal care (ANC), preterm labour, premature birth and low birth weight baby , 17. HomThis study aimed to address the gaps in the existing literature concerning the social ecologic factors that make pregnant women vulnerable to IPV. Guided by the social ecological model (SEM), the current study examined the prevalence, pattern and the association between social ecologic factors  and IPV in pregnancy in an Ethiopian context.This cross sectional study was conducted during an antenatal care visit at all health centres, and hospitals in Jimma, 177, 900 inhabitants,  and, located in Oromiya regional state, 352 km south west of Addis Ababa, Ethiopia, from November 2015 to March 30, 2016.Included were women, with a pregnancy estimated to be ≥ 24 weeks of gestation. Sample size was calculated based on a single population proportion formula using the assumptions of: 95% confidence interval, 4% degree of precision. We assumed 50% as the expected prevalence based on the average from previous studies  and a 20A standard questionnaire was developed based on the Abuse Assessment Screening (AAS) tools developed by the Nursing Research Consortium on Violence –26 and tThe study data were collected by five female, midwives/nurses working at the respective institutions, fluent in both languages (Afan Oromo and Amharic). Training was given on how to interview, handling ethical issues and maintaining confidentiality and privacy using a training manual. During data collection, to prevent incomplete and inconsistent responses, the researcher and supervisors were available for supervising and counter checking completed questionnaires.The experience of Intimate Partner Violence  was measIPV during the current pregnancy was the dependent variable; operationalized in this study as, answering ‘Yes’ to any of the following: “since you’ve been pregnant (current pregnancy), have you been slapped, kicked, or otherwise physically hurted by your intimate partner ”. While, each item under the four domains of social ecologic model  were considered as exposure variables and their responses were coded as Yes/No for each.All information were entered in EPiData and exported to SPSS (version 20.0) for analysis.Multi- collinearity or redundancy, , was cheWe used Akaike’s information criteria (AIC), –36 and tWhile adjusting for confounders (age and education of the woman and her partner), we fitted the model of each single factor, with all variables of each domain simultaneously and within the variables under each domain. After analyzing the adjusted OR, and considering the over fitting, under fitting and parsimony , 37, theWhile keeping in mind the AIC, parsimony and under fit criteria of the best model, multivariate logistic regression model was fitted to examine significant variables of the four social ecologic domain factors associated with IPV in pregnancy . The dicEthical clearance from Jimma University College of Health Sciences, IRB (Ref No: HRPGC/305/2015) and the Norwegian Regional Ethical Committee (REK),  was obtInformed written and or / verbal consent was obtained after fully informing participants about the aims and the nature of the study. Respondents were assured about the confidentiality of their response, their voluntarily participation and right to terminate at any time they want. They were also told that their care would not be affected in any way should they decide not to participate in the study.Three hundred and forty four (47.8%) of the 720 participants, mean age SD (24.9±5.0), were between15-24 years and 34.4% were first time pregnant (primi gravida) . Over onIn the current pregnancy, more than one in three women (35.6%) reported experiencing IPV, of which nearly 89% of them had experienced moderate physical violence (severity score of 1–3), slapping or pushing being the most frequent incidents (62.1%) and 18% reported being hit on their abdomen (data not shown). The life time prevalence of emotional or physical abuse by partner or someone important was 80.7% and the proportion of violence during pregnancy among ever exposed was 44%. Over half of the women (56.1%) reported physical violence victimization within the last year and the majority of the perpetrators (86.4%) were their husbands. Forced sexual activity was reported by half of the women, but only one woman was offended by a stranger.Being isolated by intimate partner from friends and family was prevalent (40%) and more than half of the women reported fear (53.8%) or psychological abuse (51.4%) in the last one year. During incidents of IPV one in three turned to their family (32.4%) or kept silent (29.5%). The major reasons to keep silent were: not to leave children behind, feeling shame, to honour the tradition that marriage is valued, having no money and nowhere to go, and fear that husband may retaliate or even kill them (data not shown).Using AIC and parsimony criteria of best model as described in the analysis section, the statistical inferences were made based on the traditional null-hypothesis testing  and interpret the result based on it may also lend strength.The subject studied is very sensitive and even stigmatizing; assessment of IPV and its factors based on self-reporting might have introduced systematic errors . Those who were exposed to IPV recently are more likely to report excessively, while those who were exposed a bit long ago may ignore or forget to report, which also might have introduced bias. Bias might have also been introduced due to unmeasured or poorly measured variables, confounders and interactions. The study had a cross sectional design (simultaneous collection of both exposure and outcome variables), and the setting is institutional based, we can neither claim causality nor generalizability, and calls for future prospective longitudinal study.Despite these limitations, this study provides valuable information and contributes to a better understanding of the magnitude of IPV in pregnancy and its multifaceted contributing factors in Ethiopia. The importance of community and societal factors in IPV warrant a public debate about IPV. Male involvement is imperative as impact of male norms related to and childhood experience of IPV are significant contributors to the risk of future IPV, as well as demonstrated in the literature, adverse events like chronic diseases and increased allostatic load . As IPV In conclusion, our study, while maintaining that it is multi-factorial , 40, IPVS1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.


Reducing neonatal mortality is a global priority, and improvements in postnatal health (PNH) practices in India are needed to do so. Intimate partner violence (IPV) may be associated with PNH practices, but little research has assessed this relationship.A cross-sectional analysis of data from a representative household sample of mothers of neonates 0–11 months old in Bihar, India was conducted. The relationship between lifetime IPV experience  and PNH practices  was assessed using multivariate logistic regression.physical violence only (29.0%) had higher odds of skin-to-skin care  and delayed bathing , but lower odds of EIBF  and exclusive breastfeeding . Mothers who had experienced sexual violence only (2.3%) had lower odds of practicing EIBF . Those who had both experiences of physical and sexual violence (14.0%) had increased odds of postpartum modern contraceptive use  and lower odds of delayed bathing .Over 45% of the 10,469 mothers experienced IPV in their lifetime. The three types of IPV experiences differentially related to PNH practices. Adjusted analyses revealed that compared to those who had never experienced IPV, women who experienced The results of this study found differing patterns of vulnerability to poor PNH practices depending on the type of IPV experienced. Efforts to increase access to health services for women experiencing IPV and to integrate IPV intervention into such service may increase PNH practices, and as a result, reduce neonatal mortality. The United Nation’s Sustainable Development Goals highlight neonatal mortality as a priority, setting a target of 12 deaths per 1000 births by 2030, a goal that will require substantial acceleration of progress for many countries . The WorIn Bihar, one of the poorest and most populous Indian states, the neonatal mortality rate is relatively high (32.2 per 1000 live births), with neonatal mortality strongly associated with inadequate PNH practices . A numbeGlobal evidence documents that women who experience IPV are less likely to engage in maternal and child health protective behaviors, including health care seeking, prior to and after pregnancy –23. StudImportant in the assessment of IPV as a risk factor for poor PNH practices is consideration of physical and sexual violence separately, as well as their co-occurrence, as a growing body of research suggests different forms of IPV relate to unique patterns of health practices , 33, 34.The current study aims to elucidate the relationship between IPV, specifically when a woman has experienced physical violence only, sexual violence only, or both forms of violence, and PNH practices among a representative sample of mothers of living infants in Bihar, India. Understanding these relationships may help guide the development of new and ongoing interventions to promote neonatal survival.The current study includes analysis of data collected for evaluation of the Ananya program, a partnership initiated in 2012 in Bihar, India, by the Government of Bihar and the Bill and Melinda Gates Foundation designed to increase maternal and child health care utilization in the public health system using a combination of supply-side and demand generation efforts . Ananya A multi-stage sampling approach was used to select villages, randomly selecting first blocks, then villages from those blocks. A listing exercise was conducted in each selected village to identify all women who had a live birth in the previous 12 months . Details on study sampling and procedures are available in a previous publication by Borkum et al. .n = 10,469); mothers of neonates requiring postnatal medical care were not excluded. Ethical approval for the original evaluation study was provided by India’s Health Ministry Screening Committee. Ethical approval for this analysis was provided by the University of California, San Diego.The survey participation rate was 87% and yielded 11,654 completed surveys from mothers of living children 0–11 months old . Women wThe primary independent variables were lifetime experiences of physical and sexual IPV considered as exclusive categories: no IPV, physical IPV only, sexual IPV only, sexual and physical IPV. Physical IPV was defined as experience of at least one of the following by a husband: being slapped, having an arm twisted or hair pulled, being pushed with his fist, being shaken or having something thrown at you, being kicked, dragged or beaten up, or attempted intentional choking or burning. Sexual IPV was measured by a yes/no response to, “Did your husband ever physically force you to have sexual intercourse with him even when you did not want to?” These measures have been validated in the Multi-country Study on Violence Against Women by the World Health Organization and are routinely included in Demographic and Health Surveys (DHS) .Outcome variables included the following healthy newborn practices: clean cord care (nothing applied to umbilicus after cutting/tying cord); kangaroo mother care (child placed unclothed with skin to skin contact on mother’s chest/abdomen following birth); early initiation of breastfeeding ; delayed bathing (first bath occurred 2 or more days after birth); postnatal care visit by a health worker within 48 h of birth; and exclusive breastfeeding . Current post-partum contraceptive use was defined as female or male sterilization, or current use of pill, injectable, intrauterine device (IUD), or condom. If contraceptive use was initiated post-partum but discontinued prior to the study, it was not considered current post-partum contraceptive use.Relevant background characteristics were included as covariates: residence in an Ananya program district (yes/no); age of mother ; age of mother at marriage (under 18 years/over 18 years old); household wealth index ;  mother’sp < 0.20 levels in bivariate analyses (results not shown). All analyses were adjusted for survey design and individual sampling weights, and were conducted using Stata 13 SE .Descriptive frequencies were calculated for all PNH practice outcomes and covariates, both overall and stratified by IPV experiences. Multivariate logistic regression models were then used to assess the association between IPV and each PNH practice, adjusting for any covariates that were significant at More than 40% of the 10,469 mothers reported ever experiencing physical IPV by their husband  and more than one in six mothers reported ever experiencing sexual violence from their husband  (Table The majority of participants (78.2%) were between the ages of 20–29 and more than two-thirds had at least two children Table . Nearly Experiencing physical IPV only was disproportionately prevalent among mothers who practiced skin-to-skin care (42.1% vs. 32.2% no IPV), were age 30+ (21.5% vs. 15% no IPV), were under age 18 when they married (52.6% vs. 39.4% of those experiencing no IPV), in the lowest wealth quartile (34.4% vs. 25.8% no IPV), had no education (62.0% vs. 47.6% no IPV), had a spouse with no education (39.5% vs. 28.5% no IPV), were from SC/ST caste (33.2% vs. 21.0% no IPV), had three or more children (46.5% vs. 36.8% no IPV), received fewer than 4 ANC visits (85.5% vs. 78.2% no IPV), did not have a skilled birth attendant (32.6% vs. 24.9% no IPV) and received a postnatal visit to discuss family planning (15.7% vs. 9.8% no IPV)  and delayed bathing , but lower odds of EIBF , and exclusive breastfeeding   and women experiencing both physical and sexual IPV were twice as likely to be using condoms   were using male or female sterilization, 31 (2.4%) oral contraception (pills), 62 (4.9%) condoms, and 11 (0.9%) other methods for preventing pregnancy. A multinomial regression assessing the association between IPV and method-specific current contraceptive use found that, relative to women who had not experienced IPV, women experiencing physical IPV only were less likely to be using oral contraception  conducted in 2015/16 found a similar rate of spousal violence among ever-married women in Bihar (43.2%) . Sexual Intimate partner violence was negatively associated with healthy breastfeeding practices. The odds of early initiation of breastfeeding were decreased by between 19% and 48% among women who experienced physical or sexual IPV, respectively. This pattern is consistent with earlier studies of the association of types of IPV and breastfeeding , 40, 41.Odds of exclusive breastfeeding for 6 months were 17% lower among women reporting physical IPV only. Uniform with earlier studies, these results could possibly indicate limited autonomy of mothers to make breastfeeding decisions, lower confidence to be able to breastfeed, or resistance to the intimate personal contact involved in breastfeeding related to trauma , 40–44.A novel finding from this study is that women who reported only physical violence were more likely to enact certain PNH practices, including skin-to-skin care and delayed bathing. A possible explanation for this relationship may be that, while experiencing physical IPV may force a woman to compromise her own health and self-care, she may work even harder than her peers to provide adequate care for her infant as a way of compensating for any disruptions her husband’s IPV may be causing within the family . In contLikelihood of postpartum contraception also differed across IPV experiences. Women who reported experiencing only physical IPV had 18% lower odds of postpartum contraception, while women reporting both sexual and physical IPV had a 35% increased odds of postpartum contraception. Significantly lower postpartum oral contraception use among women experiencing physical IPV only and significantly higher postpartum condom use among women experiencing physical and sexual IPV was observed. These findings were unexpected in light of prior research conducted with representative samples in India. These method-specific results differed from prior findings from national data of married women in India that found lower condom but higher oral contraception usage among women experiencing sexual violence . Raj et Sociodemographic characteristics were also found to relate to beneficial PNH behaviors. Being age 18 or older when married and at the time of survey, and having had a child prior to the index child were all positively associated with PNH behaviors, particularly those related to breastfeeding. Higher wealth was associated with increased odds of applying nothing to the umbilicus after cutting/tying the cord, skin-to-skin care, and current post-partum contraceptive. An unexpected trend, however, was that as spousal education increased, adherence to clean cord care was less likely. More research is needed to understand this association, as spousal education may be a marker for a particular set of husband-related characteristics that are associated with a lack of support for this PNH practice or behaviors related to neonatal care that counteract these beneficial PNH practices.Exposure to health services, including ANC, SBA, and CHW visits during the last trimester of pregnancy, emerged as experiences largely beneficial to enactment of PNH practices, even in models adjusted for IPV and other intervention services. However, SBA and four or more ANC were less likely among women experiencing physical IPV. Efforts to ensure that women who are experiencing IPV are able to access health services are needed. Women living in an Ananya program district, a program that aims to increase access to and quality of maternal and child health services, had higher odds of all assessed PNH practices, except for postnatal care, regardless of IPV exposure. Postnatal care within 48 h of childbirth, though, was not reduced among women exposed to IPV. This finding suggests that beyond being of benefit for neonates of all women, postnatal health services may be an important “touch-point” for victims of IPV, particularly in the past year. Programs like Ananya, and health services such as postnatal care, may offer a potentially important opportunity to provide support and intervene with households to help reduce or mitigate their exposure to IPV and related health vulnerabilities for both new mothers and their neonates . The AnaConsideration of the limitations of this study is important for interpreting results. Data analyzed in this study are the second cross-section of women who have recently given birth from an evaluation of a large-scale effort to improve health services, and results demonstrate a positive effect on PNH practices for those residing in the intervention districts. To address potential intervention effects on the currently assessed associations, all multivariate analyses were adjusted for exposure to this intervention. Additionally, unobserved confounding factors not accounted for may obscure true effects, though models were adjusted for a variety of highly relevant covariates in order to limit this potential. While reports of past 12 month IPV experiences likely temporarily predicate or overlap with the postnatal period in which PNH practices may have occurred, these results only provide indication of correlation and do not indicate causal relationships. One important limitation of these data is that they rely on participant self-report of PNH practices and IPV experiences from up to 11 months post-partum. This relatively long time gap may leave data vulnerable to recall and desirability bias, which could influence results to be biased either toward or away from the null hypothesis. Additionally, this analysis of a dichotomous measure of IPV experience does not provide any information on how frequency of IPV could change the association between IPV and PNH practices. The results of this study are representative of recent mothers in the state of Bihar, and cannot be generalized to other populations or regions of India or elsewhere.The current study found a high prevalence of IPV, including recent IPV, among this representative sample of recent mothers. Results indicate different patterns of vulnerability to poor PNH practices depending on the type of IPV experienced, whether physical only, sexual only, or both forms. Overall, IPV was found to be largely associated with poor PNH practices, most clearly demonstrated in its effects on breast feeding. However, a smaller subset of beneficial PNH practices were more likely among women based on the type of IPV experienced. Physical violence alone appeared to be associated with mothers’, perhaps, greater efforts to ensure care for their neonate, whereas experiences of both physical and sexual IPV, or of only sexual IPV, appeared to significantly inhibit healthy PNH practices. More research is needed to further clarify the observed associations and mechanisms behind these.The pattern of IPV experience and postpartum contraception use is unclear. The overall association between IPV and contraception use mirrored findings from other studies, but the type-specific analyses of postpartum contraception use suggests a potentially changing dynamic for the association between contraception type and type of IPV experience or a unique dynamic for postpartum contraception use.Opportunity for mitigating the negative impact of IPV on PNH behaviors may exist within health care encounters, particularly within postnatal care. Current governmental efforts to increase access and quality of maternal and neonatal health services may also facilitate women experiencing IPV to engage with PNH practices, and as a result, reduce neonatal mortality. Moreover, postnatal health care visits may provide an important opportunity for providing IPV support to victims, which could be built into existing governmental efforts to strengthen quality of care, to reduce IPV and its impact on maternal and neonatal health.


The fundamental requirement for the autonomous capsule-based self-healing process to work is that cracks need to reach the capsules and break them such that the healing agent can be released. Ignoring all other aspects, the amount of healing agents released into the crack is essential to obtain a good healing. Meanwhile, from the perspective of the capsule shapes, spherical or elongated capsules (hollow tubes/fibres) are the main morphologies used in capsule-based self-healing materials. The focus of this contribution is the description of the effects of capsule shape on the efficiency of healing agent released in capsule-based self-healing material within the framework of the theory of geometrical probability and integral geometry. Analytical models are developed to characterize the amount of healing agent released per crack area from capsules for an arbitrary crack intersecting with capsules of various shapes in a virtual capsule-based self-healing material. The average crack opening distance is chosen to be a key parameter in defining the healing potential of individual cracks in the models. Furthermore, the accuracy of the developed models was verified by comparison to the data from a published numerical simulation study. The initiation and propagation of damages/cracks at different length scales frequently result in structural degradation in materials. In structural materials, even micro-damage can lead to degradation in stiffness and durability and sometimes also to spontaneous loss of structural integrity. Furthermore, internal micro-damage is difficult to detect, repair cost of the damaged structural part is usually large and in some cases repair is impossible due to inaccessibility . In the meantime, the demand for continual improvement of engineering material performance is a common feature of many modern engineering projects and autonomous reliable repair of the internal micro-damage/cracks is desirable. To extend the structural lifetime and save maintenance costs, a fantastic strategy that once a crack or damage occurs the designed material possesses the ability to heal (recover/repair) the internal damages automatically by initiating some form of repair mechanism without any external intervention was put forward, i.e. self-healing , 2. GeneSelf-healing of fracture surfaces in polymer composites with an encapsulated healing agent has rapidly developed over the past decade , 15–19. Much progresses that a crack hits the embedded spherical/elongated capsules has been made by modeling methods and numerical simulation , 25–28. Ignoring all other aspects, the amount of healing agents released into the crack is essential to obtain a good healing. To enhance the release of healing agent per crack area, the introduction of elongated liquid filled capsules was recommended . By an eThe focus of this contribution is the description of the effects of capsule shape on the healing efficiency of healing agent released to crack surface in capsule-based self-healing materials within the framework of the theory of geometrical probability and integral geometry. Employing these tools, analytical expressions are developed to characterize the healing efficiency attributed for various shapes of capsules. The model stresses the crack opening distance, rather than the crack length, as a key parameter to characterize the healing potential of individual cracks. Furthermore, the accuracy of the developed analytical model was verified by comparison of its results with those of the published numerical simulation studies.The fracture surface of epoxy resin containing randomly dispersed spherical polymer particles or chopped glass fibres was experimentally examined to predict the self-healing efficiency of capsules by scanning electron microscopy (SEM) . In the Usually, the typical concentration of capsules mixed in self-healing material matrix is relatively low, such as in polymer composites , 35. In r uniformly distributed in the cubic sample T of side a (i.e. a representative volume element (RVE) satisfying r<<a) and VV denotes the volume fraction of capsules inside the sample. The capsule-based self-healing virtual material is considered to be a homogeneous matrix.As shown in n, hit by a random sectioning plane with area AT in the sample isV0 is the single capsule volume and N is the total amount of spherical capsules present inside the sampling region. So, the volume of healing agent released on the per area of crack is given byVRVE = a3, it obtainsAs it is deduced in the Appendix A, the probability that a spherical capsule in the cubic sample hit by a random sectioning planar crack is given by Eq . Then, ted by Eq . From EqVV⋅VRVEV0in whichX=n⋅V0ATAlternatf (f<1) which characterizes the discount is necessary and well-defined. Namely, when a capsule is fractured upon intersection by a crack, a part of the healing agent with volume fraction fV0 is released and flows in the crack. So, repeating the above process the volume of healing agent released on the per area of crack becomesIn practice, it is unlikely for a ruptured capsule to fully release its content. The volume of healing agent to be released may be discounted because of the effect of the size and the shell materials of capsule and the viscosity of healing agent, etc. Consequently, the dosage of healing agent to be released should be discounted. Hence, a factor h and radius r uniformly distributed in the cubic sample T of side a (i.e. a representative volume element (RVE) satisfying h, r << a) and VV denotes the volume fraction of capsules inside the sample. The capsule-based self-healing virtual material is considered to be a homogeneous matrix. As it is deduced in the Appendix A, the probability that a spherocylinder in the cubic sample hit by a random sectioning planar crack can be expressed by Eq . Then Eq  which characterizes the discount is interesting.For the case of spherocylindrical capsule, a similar discussion can be conducted when only a fraction of the capsule content is released from the embedded capsules as was done for the spherical capsules. Namely, a factor When spherical capsules are employed in the self-healing system, the analytical expression Eq  of self-V0 = 15.7 μm3 (i.e. a capsule diameter 2r = 3.11 μm) and volume fraction VV = 0.10, an average volume per area is found of X = 0.3107 μm3/μm2 via the presented formula Eq (3/μm2. V0)1/3, for a given volume fraction VV, can simply be derived from Eq 1/3 = 0.81, 1.61, 2.51, 3.22, 5.01, 6.31 μm, it can be drawn the line graph of X via (V0)1/3 according to Eq 1/3 is consistent with the trend as demonstrated in Eq 1/3⋅VVAs shownstigated  23]. It. ItV0 = 4π)1/3⋅VVAs shownV0 = 15.7 μm3 and an aspect ratio τ = 5 (i.e. h = 8r) and volume fraction 0.10, an average volume per area is found of Y = 0.487 μm3/μm2 via formula Eq 1/3, for a given volume fraction VV, can easily be derived by Eq 1/3 = 1.69, 2.49, 3.21, 5.00, 6.31 μm, graph of Y with respect to (V0)1/3 on the basis of Eq 1/3 is consistent with the trend as demonstrated in Eq 1/3 for different capsule concentrations and aspect ratio at random capsule orientation can be obtained. From the analytical expression Y, i.e. Eqs (Y/ (V0)1/3 is a function of the aspect ratio τ and volume fraction VV. Both the curve Y/ (V0)1/3 and the numerical values (Y/ (V0)1/3 and τ. From Y/ (V0)1/3 is improved increases as the aspect ratio increases for a given healing capacity of a single capsule. When the volume fraction and aspect ratio of embedded sphereocylindical capsules gets bigger, the deviations bewteen theoretical results and simulated values of Y/ (V0)1/3 also grows. The deviations may be originated from the ignoring of the overlapping among the embedded capsules, especially as the aspect ratio and the content are both increasing. Furthermore, for real materials containing elongated particles at a higher volume fraction (e.g. VV>0.1) alignment of the particles is almost unavoidable and isotropic distributions are unrealistic.Also, the relationship between the efficiency and the aspect ratio can be investigated from Eq . Here, Yi.e. Eqs  and 10)Y/ (V0)1/l values  given byY/X which represents the ratio of the volume of healing agent to be released on the per area of crack can be obtained from Eqs Y/X whichY/X is an analytical formula that characterizes the quotient of the determined slopes for spherocylindrical and spherical capsules at a fixed total capsule volume fraction. If the volume fraction of two types of capsules are equal and the size of spherical capsules with fixed volume which will be embedded in the matrix is given, the efficiency of healing agent released from spherocylindrical capsules employed in self-healing system increases as the aspect ratio or the volume of the type of spherocylindrical capsule grows as shown in σ = 0.2, 0.5, 1  embedded. Just when σ = 1 and τ = 1, the efficiencies are equal for the two types of capsules. Therefore, both shape and size of capsules should be jointly investigated to improve the efficiency of healing agent released in capsule-based self-healing composite materials. This point is opposed with the claim [RIF is a function of the capsule aspect ratio only and is independent of the volume fraction and the capsule volume’.Actually, he claim  that ‘foIn this contribution the effects of capsule shape on the efficiency of healing agent to be released in capsule-based self-healing composite materials are conducted. When capsules are randomly distributed in the matrix and a crack occurs and grows, the analytical expression of efficiency of healing agent released by spherical or spherocylindrical capsules are stemmed from a mathematically rigorous reasoning via the theory of geometrical probability and integral geometry. The crack opening distance is chosen to characterize the healing potential of individual cracks in the models. Furthermore, the reliabilities of the developed models can be verified by data from relevant literature information, which was implemented via numerical simulation. It was found that both shape and size of capsules should be jointly investigated to improve the efficiency of healing agent to be released in capsule-based self-healing composite materials. This point is opposed with the existing claim. As a result of the model, the volume fraction of capsules required to be embedded in matrix can be determined via the developed efficiency model for different type of shaped capsules. The results of the analytical models will serve to understand the probability of crack intersection with capsules and guide the further development of spherical or elongated liquid filled capsules in capsule-based self-healing composite materials.The probability that a randomly chosen crack plane meets the capsule could be obtained by the theory of Integral Geometry as follows.K0, K1 be convex sets in En such that K1 ⊂ K0. The probability that a randomly chosen r-plane Lr  that meets K0 also meets K1 isMr(∂K) = nWr+1(K) , and n is the dimension of space. Wr+1(K) is often called quermassintegrale or mean cross-sectional measures of a convex set K introduced by Minkowski, while Mr(∂K) is the integrals of mean curvature of the boundary ∂K of a convex set K [n = 3, r = 2, it becomesLet ex set K . For n =K1 with a capsule, a K0 with a sampling region . For a spherical capsule K1 with radius r, it holds [K0 with edge a, it hasK0 also meets the capsule K1 isIn the capsule-based self-healing model material it equates a convex body it holds W2(K1)=(=(4πr)/3,For the 2(K0)=πa,Hence, fParallel convex sets in the theory of Integral Geometry is employed. Parallel convex sets: The parallel body Kρ in the distance ρ of a convex set K is the union of all solid spheres of radius ρ the centers of which are points of K. The boundary ∂Kρ is called the parallel surface of ∂K in the distance ρ. It is worth noting that the integral of mean curvature of the boundary ∂Kρ can be expressed by the function of the integral of mean curvature of the boundary ∂K [Kr in the distance r of a segment set K with length h is the union of all solid spheres of radius r the centers of which are points of K. From Eq ,1,…,n−1.So, a spE3, when K reduces to a line segment of length h, the mean curvature integrals satisfies M1(∂K) = πh, M2(∂K) = 4π. So, the mean curvature integrals of a spherocylindrical capsule isFor the ordinary space K0 also meets the capsule K1 isNamely,from Eqs  and  are M0 = area of the boundary K; M1 = integral of mean curvature of the boundary K. Then, the integrals of mean curvature can be expressed as follows [Δ is the breadth of K in the direction u2, that is, the distance between the two support planes of K that are perpendicular to u2 and that contain K between them. The breadth of K is also called as the mean caliper diameter in the terminology of stereology [M1 is equal, up to the factor 2π, to the mean distance between parallel support planes.For a convex body  follows M1=12∫U2ereology . Thus we[Δ=M1/2π.It folloS1 Excel(XLS)Click here for additional data file.S2 Excel(XLS)Click here for additional data file.S3 Excel(XLS)Click here for additional data file.S4 Excel(XLS)Click here for additional data file.


Sensorineural hearing loss (SNHL) is the most common sensory deficit worldwide, frequently caused by noise trauma and aging, with inflammation being implicated in both pathologies. Here, we provide the first direct measurements of proinflammatory cytokines in inner ear fluid, perilymph, of adolescent and 2-year-old mice. The perilymph of adolescent mice exposed to the noise intensity resulting in permanent auditory threshold elevations had significantly increased levels of IL-6, TNF-α, and CXCL1 6 h after exposure, with CXCL1 levels being most elevated (19.3 ± 6.2 fold). We next provide the first immunohistochemical localization of CXCL1 in specific cochlear supporting cells, and its presumed receptor, Duffy antigen receptor for chemokines (DARC), in hair cells and spiral ganglion neurons. Our results demonstrate the feasibility of molecular diagnostics of SNHL using only 0.5 μL of perilymph, and motivate future sub-μL based diagnostics of human SNHL based on liquid biopsy of the inner ear to guide therapy, promote hearing protection, and monitor response to treatment. Sensorineural hearing loss (SNHL) is the most common sensory deficit in the world. Disabling SNHL currently affects nearly half a billion people , and itsNoise exposure and aging are important causes of human SNHL, and noise exposure accelerates age-related hearing loss . AccordiWe focus on proinflammatory cytokines because they play an important role in a plethora of diseases , and areWhile we , 25 and N = 19 ears), perilymph collected 6 h after exposing mice to noise levels that resulted in PTS (103 dB SPL at 8–16 kHz for 2 h) (N = 17 ears) demonstrated a statistically significant elevation of the levels of proinflammatory cytokines CXCL1 , IL-6 , and TNF-α  or neuropathic TTS (97 dB SPL at 8–16 kHz for 2 h) .For cytokines with significant elevation after PTS-causing noise, the trends in cochlear and vestibular perilymph were generally similar, with vestibular perilymph showing higher inducible fluctuations than cochlear perilymph.N = 10 ears), did not show significant changes in any of the measured cytokines, confirming the specificity of the cytokine reaction to the inner ear (N = 17 ears) did demonstrate statistically significant elevations in the levels of the same three cytokines that were elevated in perilymph 6 h after PTS-causing noise exposure .The levels of proinflammatory cytokines IL-1β and TNF-α decreased significantly from age 8 weeks (corresponding to 2 weeks after noise exposure) to 2 years in control unexposed animals . This stands in contrast to the control animals, where IL-6 levels in vPLF did not meet our criterion for change between 2 weeks and 2 years after noise exposure.In contrast to IL-1β and TNF-α, IL-6 levels increased significantly at 8 weeks of age in all analyzed samples regardless of noise exposure . The obsp = 0.0033), and at 2 weeks compared to 6 h after exposure to neuropathic TTS in vPLF (p = 0.0147). In contrast, CXCL1 levels increased significantly in the blood of 2-year-old mice compared to 6-week-old mice regardless of noise exposure .The level of CXCL1 decreased significantly at 2 years compared to 6 h after exposure to non-neuropathic TTS in cPLF -related cytokines , and immunoregulatory (IL-10 and IL-12) cytokines in the perilymph and CSF of 2-year-old animals showed decreased values compared to young animals, regardless of noise exposure . Howeverp = 0.0092 for IL-1β, p = 0.0041 for IL-6, p < 0.0001 for TNF-α, p < 0.0001 for CXCL1; 94 dB SPL group: p = 0.0048 for IL-1β, p = 0.0360 for IL-6, p = 0.0076 for TNF-α, p = 0.0256 for CXCL1; 97 dB SPL group: p = 0.0127 for IL-1β, p < 0.0001 for IL-6, p < 0.0001 for TNF-α, p = 0.0093 for CXCL1; p = 0.0385), IL-5 levels were reduced in old animals of all groups . The blood levels of immunoregulatory cytokine IL-10 were increased in old compared to young animals . In contrast, blood IL-12 levels were similar between young and old animals, regardless of noise exposure  to identify CXCL1-positive cells  and noise-traumatized mice sacrificed 6 h after PTS-causing noise exposure  showed a noticeable decrease in CXCL1 immunoreactivity in pillar cells. The reduced CXCL1 expression was detectable in the cochlear base  revealed that the cochlear cells expressing Iba1 did not co-express CXCL1    . The anaanimals) . Consideanimals) . In contanimals) , DARC imanimals) . A semi-N = 4 animals Within the peripheral vestibular system, specific immunoreactivity for DARC was found within the crista ampullaris  by RT-PCR in Sprague-Dawley rats . In a foTnip1, a gene encoding the “tumor necrosis factor, alpha-induced protein 3” was expressed at higher levels in mice resistant to noise exposure. This protein is known to inhibit TNF-mediated apoptosis and NF-kappa B activation.When comparing mouse strains with different susceptibility to noise-induced hearing loss, several immune-related genes were reported to be upregulated in the susceptible mice . In addiHaemophilus influenzae to model acute otitis media  within the mammalian cochlea, prior studies that analyzed pooled inner ear tissue noted upregulation of CXCL1 mRNA during cochlear inflammation and development. Specifically, CXCL1 mRNA was upregulated in the inner ear tissue of mice with chronic otitis media, based on qRT-PCR analysis . FurtherOur finding of CXCL1 expression in the pillar cells, Deiters cells, interdental cells, and vestibular supporting cells of control animals suggests constitutive CXCL1 expression in the inner ear under physiologic conditions, and implicates these cell types in immune and inflammatory regulation in the inner ear. Our finding of reduced CXCL1 expression in pillar cells coupled with the elevated CXCL1 levels in perilymph after acoustic trauma suggests CXCL1 release into perilymph after pathologic noise exposure that damages pillar cells. The noise-induced elevation of CXCL1 levels in perilymph could also reflect higher production in the cochlear microenvironment. Since macrophages did not express CXCL1 6 h after acoustic trauma, the CXCL1-positive supporting cells appear to be the main producers of CXCL1. Relevantly, both pillar and Deiters cells express transforming growth factor-β-activated kinase-1 (TAK1) , a potenApart from its proinflammatory activity, CXCL1 may play a neuromodulatory role in the inner ear given the close proximity of nerve fibers within the organ of Corti and CXCL1-expressing supporting cells . This hyPlasmodium vivax and Plasmodium knowlesi), its primary function is the sequestration and transcytosis of chemokines  was noted at 3 months  of either sex were used in an estimated 50/50 ratio. They were randomly assigned to different noise exposure groups or to the control group at 6 weeks of age. Animal weight was comparable in all groups. Experiments were designed to typically have one mouse from each group housed in any given cage. When animals were not used for one of the interventions, they were kept in our animal care facility with 0 dB SPL . A totalExperiments were carried out as described in the publication from our laboratory that established the noise levels that cause neuropathic TTS, non-neuropathic TTS and PTS in the cochlear base, specifically the areas where tones with frequencies of ~25 kHz and higher are processed . BrieflyFor perilymph sampling we used the approach developed by Salt's and Hirose's laboratories . BrieflyAfter bilateral specimen collection from the PSCs, CSF was collected from the cisterna magna as previously described . BrieflyAs the final procedure for every animal, a blood sample was obtained by cardiac puncture after thoracotomy. The sample was transferred into a serum gel with a clotting activator tube  and left standing upright at room temperature for 30 min. It was then spun down  and the supernatant was transferred into an Eppendorf tube that was sealed with parafilm and stored at −80°C.The V-PLEX Proinflammatory Panel 1 Mouse Kit  was used to analyze the perilymph, CSF, and blood samples. It is an immunoassay based on electrochemiluminescence that quantifies the levels of the following cytokines: IFN-γ, IL-1β, IL-2, IL-4, IL-5, IL-6, CXCL1, IL-10, IL-12p70, and TNF-α. Briefly, samples and corresponding standards  were added into wells of MSD MULTI-SPOT 96-well plates, pre-coated with capture antibodies, and incubated for 2 h at room temperature. Plates were washed three times with 150 μL/well of washing buffer, and 25 μL of detection antibody solution containing antibody conjugated with electrochemiluminescent labels (MSD SULFO-TAG) was applied into each well. Samples were incubated for an additional two h, then washed as described before, and treated with 2X Read Buffer T. Electrochemiluminescence was measured on the matching MSD SI2400 instrument. Concentration of cytokines was determined from electrochemiluminescence signals fitted to the calibration curve.Cochlear whole mounts were dissected and mounted as described previously . Immunofp < 0.05), pair-wise comparison was performed and Bonferroni correction was applied for multiple comparisons. When variances were not equal, Kruskal-Wallis test was used. If the test was significant (p < 0.05), Wilcoxon rank-sum test was applied, followed by Bonferroni correction. Composite graphs showing individual and average values were constructed using GraphPad PRISM.GraphPad PRISM  was used for all statistical analyses. For cytokine measurements, Bartlett's test was used to check for homoscedasticity. When variances among the groups were equal, one-way ANOVA was used to compare the groups. If ANOVA was significant (All datasets generated for this study are included in the manuscript/The animal study was reviewed and approved by Institutional Animal Care and Use Committee at Massachusetts Eye and Ear.KMS conceived the project, designed experiments, and supervised all aspects of research. Perilymph samples were collected by LDL, TF, and VYS. Noise exposures were carried out by LDL and RS. Dissection of whole mounts was performed by LDL, SV, and RS. Immunohistochemical staining, confocal microscopy, and image analysis was performed by SV. Perilymph samples were processed by LDL, SV, and LX. TF performed statistical analyses of perilymph samples. LDL, SV, and KMS wrote the manuscript with editorial input from all other authors.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.