The growth in Intimate Partner Violence (IPV) cases among couples in Nigeria has been significant in recent years. Victims, which are often females, face numerous health challenges, including early death. I examined the linkages between spousal age differences and IPV in Nigeria.n = 6765). Intimate partner violence was measured using 13-item questions. Data were analyzed using the logistic regression model (α = .05).The couples recode data section of the 2013 Nigeria Demographic Health and Survey was used  and 1.35  higher in households where the spousal age difference was 0–4 and 5–9 years respectively, than the likelihoods among those with a spousal age difference ≥ 15 years, but the strength of the association weakens when other variables were included in the model.The mean spousal age difference was 8.20 ± 5.0 years. About 23.5, 18.0, 13.5 and 4.7% of couples surveyed had experienced some form of IPV, emotional, physical and sexual violence respectively. Also, IPV prevalence was 27.0, 23.7, 22.0 and 18.7% among couples with age differences of 0–4, 5–9, 10–14 and ≥15 years respectively; this pattern was exhibited across all domains of IPV. Among women who experienced physical violence, 20.5% had only bruises, 8.0% had at least one case of eye injuries, sprains and/or dislocations, and 3.7% had either one or more cases of wounds, broken bones or broken teeth. The identified predictors of IPV were: family size, ethnicity, household wealth, education, number of marital unions and husband drinks alcohol. The unadjusted likelihood of IPV was 1.60 (C.The level of IPV was generally high in Nigeria, but it reduced with increasing spousal age difference. This study underscores the need for men to reach a certain level of maturity before marriage, as this is likely to reduce the level of IPV in Nigeria. Violence against women is “any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life” . IntimatLiterature on IPV in low-income countries has focused largely on Asia –6 and soSpousal healthy relations and a successful married life are the result of many factors. One salient factor, which usually goes unnoticed is spousal age difference. Spousal age difference refers to the difference between the ages of wife and husband. The tradition of male dominance in marriage is still prevalent in Nigeria, where, apart from a few exceptions, men marry women that are younger than they are . This coWomen bear the overwhelming burden of IPV in Nigeria. The 1993 United Nations General Assembly resolution recommends the promotion of research, especially regarding domestic violence, relating to the prevalence of different forms of violence against women, and encourages research on the consequences of violence against women [A growing number of research has been conducted into the factors associated with IPV and its three domains , 12, 13.In sub-Saharan Africa, the IPV prevalence ranges from 30.5% in Nigeria to 43.4% in Zimbabwe, 45.3% in Kenya, 45.5% in Mozambique, 53.9% in Zambia and 57.6% in Cameroun . A studyIn order to understand IPV within a family violence structure, different frameworks have been used by sociologists. The family violence perspective views conflict between family members as universal and inevitable, and holds the view that most family violence is not the result of individual pathology but that it is a “normal part of family life in most societies” . Straus A nested ecological theory by Dutton and Nicholls states that more precise variables are viewed as ‘nested in’ broader variables . This thThis study was conducted in Nigeria, a country in the West African sub-region. By geographic definition, Nigeria is predominantly a rural country and the level of illiteracy is high. A national survey found that the median age at first marriage for men and women was 18.1 and 27.2 years respectively .The study was cross-sectional population-based and used weighted 2013 Nigeria Demographic and Health Survey data, with a focus on the couple recode section of the data. It was a nationally representative sample, with participants selected across all the states in Nigeria. The survey used as a sampling frame the list of enumeration areas (EAs). Administratively, Nigeria is divided into 36 states and a Federal Capital Territory (FCT). These states are subdivided into 774 LGAs, and each LGA is divided into localities. Each locality was subdivided into EAs. The EAs, which were the primary sampling units (PSU), were used as a cluster with a minimum size of 80 households. The sample was selected using a stratified three-stage cluster design, consisting of 904 clusters, 372 in urban areas and 532 in rural areas. A complete listing of households and a mapping exercise were carried out in each cluster, with the resulting lists of households serving as the sampling frame for the selection of households. All regular households were listed. Global Positioning System (GPS) receivers were used to calculate the coordinates of the sample clusters. A fixed sample of 45 households was selected per cluster. In this study, a sample of one eligible woman in each household was randomly selected to be asked questions regarding domestic violence .Only couples with complete information on variables that were used for the generation of IPV and age difference were included in the study. A small number of cases, where women were older than their husbands, were excluded. Thus, the total sample of couples included in the study was 6765. Intimate partner violence was created using information on the following items:The items 1–3, 4–10 and 11–13 above constitute the emotional violence (EV), physical violence (PV) and sexual violence (SV) domains respectively, as measured by the demographic health and survey . In ordeThe main independent variable was spousal age difference, which was generated by subtracting the ages of the women from the ages of their husbands. These age gaps were later categorized as 0–4, 5–9, 10–14 and ≥15 years with a view to examining which spousal age gap inhibits or promotes IPV, other than using age difference as a continuous variable in the analysis. Other independent variables include the following: number of living children, residence, ethnicity, religion, household wealth, education, marriage type, husband drinking alcohol, husband’s education, number of marital unions and empowerment.p-value cut-off point of 0.25 was included in the first model. In the iterative process of variable selection, covariates were removed from the model if they were not significant  and not a confounder. At the end of the iterative process of deleting, refitting, and verifying, the final model was fitted.Data were analyzed using t-test, Chi-square and logistic regression at 5% level of significance. The t-test was used to determine the mean age difference by IPV. The Chi-square was used to examine the association between IPV, EV, PV, SV and socio-demographic characteristics, including spousal age difference. Due to the dichotomous nature of each of the dependent variable, we used the logistic regression model to identify the predictors of IPV and other domains of violence. The selection of variables into the logistic regression was done by running a bivariate analysis of the dependent variable and an independent variable. Thereafter, any statistically significant variable based on the Wald test from logistic regression and a Two models (unadjusted and adjusted) were used to examine the relationship between age difference and IPV, EV, PV, SV. The unadjusted models Eq.  were the0, βpi are the regression parameters, xi are the independent variables, and pi represents the proportion of women who have experienced IPV in the ith category of a particular variable.βIn Table p < 0.001) and 27.0%-to-18.7% (p < 0.001) respectively. In the case of sexual violence, the pattern was different from the patterns exhibited by IPV, physical, and emotional violence. The percentage of women who had experienced sexual violence was 4.6%, 4.9%, 4.7% and 4.2% among couples with the age differences of 0–4, 5–9, 10–14 and 15+ years respectively (p > 0.05).Figure The data as shown in Fig. p < 0.001).The data presented in Table Ethnicity and religion were significantly associated with all the domains of violence. In the main religious groups in Nigeria, the data show that Igbo women experienced more IPV (28.0%), emotional (24.0%) and sexual violence (4.3%) than did women in the Yoruba and Igbo ethnic groups, but Yoruba women (17.2%) experienced the physical violence among the three ethnic groups. A higher proportion of Christian women than Muslim women experienced IPV (33.8% vs 15.8%), emotional (25.4% vs 12.4%), physical (22.6% vs 6.6%) and sexual violence (5.7% vs 4.0%). The data further show that emotional violence was the only violence domain that was not associated with household wealth. A slight disparity existed between the percentage of women who experienced any type of IPV, physical or sexual violence among those who come from middle-income and rich households, but the margin was wider between middle-class and poor households. The percentage of women who experienced IPV forms a U-shape, with women with no formal education and those with higher education having previously experienced lower levels of violence from their intimate partner than did women who had primary and secondary education. For instance, the prevalence of IPV was 16.0%, 32.5%, 29.6% and 19.0% among those with no formal, primary, secondary and higher education respectively. This was also the pattern exhibited based on the husband’s level of education. Surprisingly, IPV was found to be higher among highly empowered women than those in low level of empowerment.The percentage of women who reported that they had experienced violence from their intimate partner was strikingly higher among spouses of men who drink alcohol. With regard to previous experiences of any type of IPV, the percentage of women was 45.4% among women whose husbands drank alcohol, compared to 18.5% among women whose husbands did not drink alcohol. In the case of emotional violence, it was 35.1% and 14.1% among women whose husbands drank alcohol and whose husbands were non-drinkers respectively. In the case of physical violence, 33.2% of women whose husbands drank alcohol had experienced such violence, compared to 9.1% of women whose husbands did not drink alcohol.I = 1.30–1.98, p < 0.001), 1.35  and 1.23  higher in households where the spousal age differences were 0–4, 5–9 and 10–14 respectively, than among those with a spousal age difference of at least 15 years. In particular, being in spousal age difference groups 0–4 , 5–9 , and 10–14  years seemed to predispose women to physical violence than among couples where the age difference was 15 years and above. Spousal age difference was not found to be significantly related to sexual violence.The data as presented in Table I = 1.65–2.63, p < 0.001), 2.87  and 2.46  times more likely among couples who had given birth to 1–2, 3–4 and ≥5 children respectively than among couples who have no children; this pattern was similar to the emotional and physical violence experienced. Among all the types of violence, only the sexual domain shows a significant relationship with place of residence. In this case, the likelihood of sexual violence was found to be higher in the rural areas  than in the urban areas. In terms of the relationship between ethnicity and IPV, the odds of IPV, emotional violence and physical violence were lowest among Hausa/Fulani women and highest among Igbo women. However, Yoruba women experienced lower sexual violence  than Hausa/Fulani women. In addition, women who practiced the Islamic religion were less likely to experience IPV or any of IPV domains than their Christianity counterparts were. The data further show that the risk of any violence type was significantly higher in households where the husbands drank alcohol. Moreover, the likelihood of IPV, emotional violence and physical violence was 1.48 , 1.39  and 1.50  higher among women with a high empowerment status than among women with a low empowerment status, although there was no significant relationship between empowerment status and sexual violence.The risk of IPV was higher among couples who have at least one child than among those without any children. In particular, the odds ratio of IPV was 2.09 , 2.37  and 2.15  higher among couples who had 1–2, 3–4 and 5+ living children respectively, than among those who had never had any children. This statistically significant pattern was also exhibited by physical, emotional violence and number of living children. The Igbo and Yoruba women were more likely to have experienced IPV, emotional and physical violence than were Hausa/Fulani women. The odds of experiencing IPV was 1.80  and 1.93  higher among Igbo and Yoruba women respectively than among their Hausa/Fulani counterparts. With regard to previous experiences of physical violence, Yoruba women had a higher risk  than did Hausa/Fulani women. Also the chance of sexual violence was higher among Igbo women  than among Hausa/Fulani women. Having been married more than once  furthermore predisposes Nigerian women to a higher risk of sexual violence than was the case among those who had only been married once.The likelihood of IPV was 1.78c  times higher among women whose husbands drank alcohol; this pattern was found across the three domains of violence. The likelihood of IPV, physical violence and sexual violence falls consistently with increasing level of household wealth. While the data showed no significant difference between women with no formal education and those who had a higher level of education with regard to the violence they had experienced, whether IPV, sexual or emotional violence, the risks were significantly higher among women with a primary and secondary level of education than among those with no formal education. The likelihood of IPV was 1.57  and 1.55  higher among women with primary and secondary education respectively than among those with no formal education. For sexual violence, the chance was 1.60  and 1.70  higher among women with primary and secondary education than among those with no formal education.The likelihood of IPV was 2.25 (C.Intimate partner violence is a problem that potentially affects every family, although its severity level varies across socio-cultural characteristics , 12. In The study revealed that the average spousal age difference was 8.20 ± 5.0 years, and the mean difference was lower among households where wives have experienced some form of IPV. This implies that men who commit IPV are much older than their wives. Traditionally, men marry women who are younger than they are; the persistent harsh economic conditions that have lasted for about four decades in Nigeria have led to men only marrying later in life, which further widens the age gap between couples. The expectation is that IPV should reduce where the spousal age difference is wider, because in such instances, the man is expected to be more mature than his wife, and thus should be able to tolerate some inadequacies of his wife in terms of behavioral attitudes. However, it seems that this expectation is not correct, as reviewed in the theoretical framework in the background section of this paper. Although the odds of IPV significantly reduced as spousal age difference increases, spousal age difference was not found to be a predictor of IPV. This finding is consistent with the outcome of the study conducted in America .In this study, about one in every four women had experienced IPV, while emotional violence was found to be the most prevalent of the domains of IPV, followed by physical and sexual violence in that order. This variation pattern in the prevalence of IPV and its domains echoes the findings of studies previously conducted in Nigeria and some parts of Africa , 11, 14.The number of years that couples had been married appeared to be important to IPV . The shaThe chance that a woman would experience violence from her intimate partner was found to increase, as the family size increased; it was lowest among couples who did not have children. The prolonged harsh economic conditions in Nigeria, combined with the high levels of unemployment, which has caused the failure of some men to discharge their responsibilities as head of the household could be responsible for this finding. All things being equal, under the current economic condition in Nigeria, it is assumed that families with a lower number of children may find it easier to meet their immediate needs than families with a larger number of children. Where resources are lacking and when facing numerous family needs that are echoed by the wife, the husband may resort to violence . This isThe cultural environment is important when discussing issues relating to IPV . In marrEducation is a way of breaking the prevalence of male dominance in marriage, irrespective of the spousal age difference. It is known that women who are more educated are also more likely to be aware of their fundamental human rights and thus more empowered within the household in terms of their involvement in family issues/decisions than women who have received less education. The tussle for power and the non-compliance or disagreement of women with some of the rules laid down by the husband may trigger violence within the marriage. As one of the important predictors of IPV in this study, the positive relationship between level of education and IPV, where increasing the level of education was found to be non-protective of IPV, has been established in the literature  but the This study had some limitations. Firstly, it is likely that IPV cases are under-reported, because women are often afraid or reluctant to report it, particularly among low-income groups. It is also likely that some communities may have reservations about reporting IPV in general. These certainly will have an implication on the prevalence of IPV found in this study. Therefore, our results may not be representative of all cases of IPV and may be biased towards populations with more sensitization towards IPV or a greater awareness of programmes relating to IPV. According to the findings of this study, however, more efforts are needed to reduce the level of IPV, as stipulated by the SDGs. Secondly, it is also likely that the number of IPV cases was grossly under-reported because women who were hospitalized as a result of experiencing violence during the course of the survey, were not captured due to the population-based nature of this study. Thirdly, the cross-sectional nature of this study suggests that causality cannot be clearly established, and therefore the readers of this article should interpret the findings with caution. Lastly, family arrangement has a direct relation to IPV, but that has not been covered because the data did not capture information that could be used for such analysis.The level of IPV found in this study was high; it appeared to reduce with increasing spousal age difference. Spousal age difference is not a predictor of IPV, but a higher spousal age difference was found to be protective of IPV. Therefore, this study recommends that men need to be sufficiently mature before entering into marriage, as this will reduce the level of IPV in Nigeria. Strategies to eradicate IPV in Nigeria should target couples with lower age differences as well as families where the husband drinks alcohol. While the age difference may not really be an important factor in examining IPV amidst other covariates, the predictors of IPV found in this study were: family size, ethnicity, household wealth, education, marital duration and husband’s alcohol consumption. These factors should be taken into consideration when designing frameworks on reducing IPV in Nigeria. The findings underscore the risk associated with the influence of spousal age difference on IPV. Context-specific qualitative studies are needed in Nigeria to explore the relationship between partner age differences and IPV further.


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.


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.