Nexus Between Perinatal Intimate Partner Viloence and Postpartum Contraception Among Currently Married Women in Wolaita Zone, Southern Ethiopia: A Mixed- Method Study
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Date
2023-05
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Addis Ababa University
Abstract
Background: Intimate partner violence (IPV) is the most pervasive breach of human rights
worldwide and a serious public health concern that affects millions of women, particularly those
of reproductive age. Women of all ages may experience IPV, but it is magnified when the
victims are pregnant or postpartum because of its detrimental effects on the mother, fetus, and
newborn. Violence around the time of pregnancy is critical and is associated with poor physical
and psychosocial health, some of which may impact future childbearing and contraceptive use.
Women in violent relationships may have difficulty in making contraceptive decisions, which
contradicts family planning as a human right. Thus, a deep understanding of the association
between IPV during the perinatal period and contraceptive use would help in shaping future
plans for women’s health and public health in general.
Objectives: The objectives of this dissertation were to explore postpartum women’s lived
experiences of perinatal intimate partner violence (PIPV), assess the prevalence and associated
factors of PIPV, and its effect on postpartum modern contraception in the Wolaita zone, southern
Ethiopia.
Method: The study was conducted between October 2019 and January 2021 in the Wolaita
Zone, southern Ethiopia. A convergent mixed-methods study design was employed, using both
qualitative (phenomenological study design) and quantitative methods (cross-sectional and
classical cohort study designs). A total of 1,342 postpartum women identified from 38 clusters (“
Kebeles”) were selected using a multistage-cluster sampling method. A qualitative study was
conducted to explore postpartum women's lived experiences of PIPV and the perspectives of
healthcare providers as key informants. It was employed with a conveniently selected sample of
22 in-depth interviewees and five health extension workers. Each audio recording was
transcribed verbatim, coded and analyzed using thematic content analysis. Structured,
interviewer-administered questionnaires were used to collect the quantitative data. Descriptive
analysis was performed by computing summary statistics and proportions. Univariate, bivariate,
and multivariate analyses were performed based on the objectives of the study. Multilevel
regression models were used to identify explanatory variables that affect the outcomes of interest
at different levels to estimate the clustering effect. Odds, time, risk ratios, and β-coefficients,
along with the 95% CI, were used to show the strengths of associations.
Results: The qualitative results revealed that several of the interviewed women had been
subjected to partner violence before, during, and after pregnancy, and frequently talked about the
regularity of partner violence during the perinatal period. Multiple interviewees noted that
violence during pregnancy was exacerbated and increased during the postpartum period.
Additionally, a sizeable proportion of the interviewed women delineated that some partners were
a serious threat to their wives and infants during the postpartum period. Participants linked PIPV
with suspicion about the paternity of the newborn, male-child preference, partner infidelity and
jealousy, contraceptive usage, husband’s alcohol consumption, indifference to shortages of
household necessities, improper parenting, and financial problems.
The overall prevalence of PIPV was estimated to be 40% (95% CI: 36.9%–44.6%). About 18%
of women reported experiencing continuous abuse over the perinatal period. The odds of PIPV
was more than two times higher among women living in rural areas (adjusted odds ratio (aOR) =
2.46, 95% CI: 1.21–5.01). Women living in neighborhoods with higher IPV favoring norms
(aOR=1.49, 95% CI:1.01-2.20), higher female literacy (aOR = 2.84, 95% CI: 1.62–5.01), higher
female autonomy (aOR = 2.06, 95% CI:1.36-3.12), and neighborhoods with lower wealth status
(aOR = 1.74, 95% CI: 1.14–2.66) had higher odds of encountering PIPV.
Of the study participants, 62% (95% CI: 59.1%–64.5%) started the first modern contraceptive
method within the first year postpartum. The most commonly used modern methods were
injectables (44.1%), pills (16.9%), and implants (15.3%). Women who reported PIPV (aRR =
0.69; 95% CI: 0.50-0.97) and women who reported no menstrual resumption (aRR = 0.54; 95%
CI: 0.48-0.62) had a lower risk of adopting contraceptive methods after childbirth than their
counterparts. The risk of using postpartum modern methods among women who delivered in
health facilities was 1.58 times as high as the risk of using postpartum modern methods among
those who delivered at home (aRR = 1.58; 95% CI: 1.41–1.78.).
The median survival time to the adoption of the first postpartum modern contraceptive method
was six months. Living in a rural area (adjusted time ratio, or aTR, = 1.44, 95% CI: 1.06–1.99),
in the middle household wealth quintile (aTR = 1.10, 95% CI: 1.02-1.19), or in a community
with a high rate of early marriage (aTR = 1.14, 95% CI: 1.01–1.28) predicted a longer time to
adopt modern contraception. Moreover, women with no history of perinatal abuse took less time
than those with a history of abuse to start postpartum contraception (aTR = 0.71, 95% CI: 0.66-
0.78).
Conclusion: This study highlights that postpartum women in the study area are experiencing
continuous and severe forms of PIPV. The circumstances that lead to PIPV are multifactorial. A
considerable proportion of postpartum women reported PIPV, with nearly a fifth experiencing
continuous violence before, during, and after pregnancy. The study also found that PIPV
victimization was strongly influenced by individual and contextual factors, with significant
heterogeneity between clusters. In effect, the complex patterns of interplaying factors operating
at different levels could put pregnant or postpartum women at a higher risk of perinatal abuse.
Furthermore, more than half of the women in the study area adopted postpartum contraceptive
methods, but those who reported PIPV were less likely to use contraceptives compared to the
women who did not experience it. Similarly, being employed, living in a middle-income
household, and giving birth in a health facility are predicted to enhance postpartum modern
contraceptive adoption, whereas having a husband with a secondary or higher education and
reporting no menstrual resumption are thought to lower modern method use after childbirth.
In the study area, women took a long time to adopt modern methods after childbirth. The longer
time to start modern postpartum contraception was significantly associated with rural residence,
poor household wealth status, a history of perinatal abuse, and a high rate of early marriage in
the community.
Thus, strengthening community-based interventions to alleviate women’s IPV-favourable
norms, improving women's socio-economic and educational status, reducing early marriage, and
promoting skilled care utilization in the community, particularly among rural women, are
recommended. Moreover, integrating intimate partner violence screening and psychosocial
support programs into family planning services in the continuum of care will likely improve
postpartum contraceptive use behaviors.
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Keywords
Postpartum women, perinatal, intimate partner, violence, modern contraception, prospective study, Ethiopia