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  • Research article
  • Open Access
  • Open Peer Review

Associations of intimate partner violence with postnatal health practices in Bihar, India

  • 1,
  • 1,
  • 1,
  • 2,
  • 2,
  • 2 and
  • 1Email author
BMC Pregnancy and ChildbirthBMC series – open, inclusive and trusted201717:398

https://doi.org/10.1186/s12884-017-1577-0

  • Received: 21 December 2016
  • Accepted: 15 November 2017
  • Published:
Open Peer Review reports

Abstract

Background

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.

Methods

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 (physical violence only, sexual violence only, or both physical and sexual violence) and PNH practices [clean cord care, kangaroo mother care, early initiation of breastfeeding (EIBF), delayed bathing, receipt of a postnatal care visit, exclusive breastfeeding, and current post-partum contraceptive use] was assessed using multivariate logistic regression.

Results

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 physical violence only (29.0%) had higher odds of skin-to-skin care (AOR = 1.67, 95% CI = 1.42, 1.96) and delayed bathing (AOR = 1.19, 95% CI = 1.03, 1.37), but lower odds of EIBF (AOR = 0.81, 95% CI = 0.70, 0.93) and exclusive breastfeeding (AOR = 0.83, 95% CI = 0.71, 0.96). Mothers who had experienced sexual violence only (2.3%) had lower odds of practicing EIBF (AOR = 0.52, 95% CI = 0.36, 0.76). Those who had both experiences of physical and sexual violence (14.0%) had increased odds of postpartum modern contraceptive use (AOR = 1.35, 95% CI = 1.07, 1.71) and lower odds of delayed bathing (AOR = 0.76, 95% CI = 0.63, 0.91).

Conclusions

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.

Keywords

  • Intimate partner violence
  • Post-natal health
  • Breastfeeding
  • Post-partum contraception

Background

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 [1]. Practices known to promote neonatal health are key to reaching this target, as evidence suggests that postnatal care within 2 days of birth, clean cord care and early initiation of breastfeeding could eliminate 30–60%, 37%, and 16%–44% of neonatal deaths, respectively [27]. The World Health Organization recommends that women should receive postnatal care that teaches new mothers these healthy post-natal health (PNH) practices within the first 24 hours, followed by check-ups on the second or third day, and then on the seventh day after giving birth [8, 9]. In India, one of the most populous countries in the world, and where the neonatal mortality rate is 28 per 1000 live births, national programs to strengthen maternal and neonatal health services have likely contributed to reducing the neonatal mortality rate by half over the last 15 years, yet low rates of healthy PNH practices persist, likely inhibiting further improvement [1013]. Strengthening PNH practices in India is essential to reducing neonatal mortality.

In 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 [13]. A number of social factors are associated with PNH practices, including wealth, maternal and paternal education, caste, and religion, indicating varying PNH practices across populations [1416]. Intimate partner violence (IPV), a human rights violation faced by more than one in three married women in India and two in five married women in Bihar, has been documented to play an important role in maternal and infant health in India and other national contexts, and may have important implications for PNH practices [11, 1720].

Global 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 [2123]. Studies indicate that IPV compromises women’s health practices indirectly, by inducing stress/anxiety and depression, which can impede their ability to alter their circumstances and uptake social and health services, but also directly, as abusive male partners may actively prevent women’s protective health behaviors [21, 2426]. Less research on this topic has focused on the postnatal period specifically, despite this being a similarly critical period for maternal and child health. The limited research on IPV and the postnatal period has focused on breastfeeding practices and consistently demonstrates that IPV is associated with lower likelihood of exclusively breastfeeding infants in the first 6 months of life [2731]. Research from India also indicates physical and sexual IPV history is associated with not using contraception postpartum [23]. Despite this evidence linking IPV and a subset of PNH practices, we found no published research from India or globally that was specific to key PNH practices beyond breastfeeding and contraceptive use, such as clean cord care, kangaroo mother care (skin-to-skin care), and delayed bathing of newborns [28, 3032]. Nor could we identify research on the association between IPV and post-partum clinical care, although extensive research from India and elsewhere indicates that IPV is associated with delayed or no antenatal care utilization [3335]. The current study attempts to address this significant gap in research regarding associations between IPV and post-partum health practices which may reduce neonatal mortality.

Important 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 [18, 25, 33, 34]. Previous research in India has identified that women experiencing only physical IPV are less likely than those reporting no IPV to utilize sexual health services [23, 36]. Indian women experiencing only sexual IPV have been found to be more likely to use modern contraceptives compared to women reporting no IPV [23, 34]. In the same study, however, no association was found between experiencing physical IPV alone and modern contraceptive use [23, 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.

Methods

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 [37]. Ananya was implemented using a two-armed quasi-experimental design in which eight intervention districts were compared to the remaining 30 standard care districts. Baseline data, collected in 2012, did not include any measures of IPV, therefore the current analysis is limited to cross-sectional data from the second statewide household survey collected January to April 2014 from a representative sample of mothers of 0–11 month old infants. All data were collected by trained female study staff, subsequent to acquisition of written informed consent.

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 (about 13 women per village, on average). Details on study sampling and procedures are available in a previous publication by Borkum et al. [38].

The survey participation rate was 87% and yielded 11,654 completed surveys from mothers of living children 0–11 months old [38]. Women who had ever been married with a living, singleton child aged 0–11 months and were not pregnant at the time of interview were included in this analysis (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.

Measures

The 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) [21].

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 (EIBF; newborn was breastfed within 1 h of birth); 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 (child received only breastmilk in 24 h prior to the survey for children <6 months; 6 months of exclusive breastfeeding reported for children 6–11 months). 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 (15–19, 20–24, 25–29, 30+); age of mother at marriage (under 18 years/over 18 years old); household wealth index (quartiles; a variable constructed via principle component analysis of household characteristics and assets following the technique used in DHS); [39] mother’s education (none, primary [1–8 years], secondary [9+ years]); husband’s education (none, primary [1–8 years], secondary [9+ years]); religion/caste status (belonging to either of the minority, most-marginalized social groups in India; Muslim, scheduled caste/scheduled tribe [SC/ST], or neither); gender of focal child (male/female); parity of mother (1 birth, 2 births, 3+ births); prior neonatal death or stillbirth (one or more children stillborn or died as neonate prior to focal child/none); antenatal care visits (ANC; <4 ANC visits, 4+ ANC visits); skilled birth attendant (SBA) at birth of focal child (yes/no); age of focal child (in months); and visits of community health worker (CHW) in late pregnancy (<2/2+ CHW visits in last trimester). For analyses related to current post-partum contraceptive use, the covariate of postnatal CHW visits in which family planning was discussed (yes/no) was also included.

Data analysis

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 p < 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 (Stata Corp, College Station, TX).

Results

More than 40% of the 10,469 mothers reported ever experiencing physical IPV by their husband (29.0% only physical violence, 14.0% physical violence accompanied by sexual violence) and more than one in six mothers reported ever experiencing sexual violence from their husband (2.3% sexual violence only, 14.0% sexual violence accompanied by physical violence) (Table 1). Almost all women (98%) who experienced IPV in their lifetimes reported recent experiences of IPV, with similar prevalence between recent and lifetime experiences (IPV in the last 12 months: physical only = 28.3%, sexual only = 2.8%, physical and sexual = 12.3%).
Table 1

Frequencies of maternal and neonatal care outcomes and background characteristics, overall and stratified by experiences of physical and sexual intimate partner violence (N = 10,469)

 

Total

Lifetime experience of intimate partner violence

  

No IPV

Physical IPV only

Sexual IPV only

Physical and Sexual IPV

Unwtd. N

%

(95% CI)

Unwtd. N

%

(95% CI)

Unwtd. N

%

(95% CI)

Unwtd. N

%

(95% CI)

Unwtd. N

%

(95% CI)

Total

10,469

5743

54.8%

(53.0–56.5)

3019

29.0%

(27.5–30.6)

241

2.3%

(1.8–2.8)

1466

14.0%

(12.8–15.3)

Outcomes

 Clean cord care

  No

7920

75.0%

(73.4–76.6)

4316

74.1%

(72.0–76.1)

2303

75.1%

(72.3–77.7)

186

77.8%

(68.7–84.8)

1115

78.0%

(74.5–81.1)

  Yes

2549

25.0%

(23.4–26.6)

1427

25.9%

(23.9–28.0)

716

24.9%

(22.3–27.7)

55

22.2%

(15.2–31.3)

351

22.0%

(18.9–25.5)

 Skin-to-skin care

  No

6935

65.4%

(63.0–67.7)

3944

67.8%

(64.9–70.5)

1781

57.9%

(54.3–61.3)

154

63.0%

(52.9–72.1)

1056

71.8%

(67.1–76.2)

  Yes

3534

34.6%

(32.3–37.0)

1799

32.2%

(29.5–35.1)

1238

42.1%

(38.7–45.7)

87

37.0%

(27.9–47.1)

410

28.2%

(23.8–32.9)

 Early initiation of breastfeeding

  No

5443

51.8%

(50.0–53.7)

2900

49.3%

(47.1–51.5)

1629

54.5%

(51.5–57.5)

139

65.4%

(56.8–73.1)

775

54.0%

(49.4–58.6)

  Yes

5026

48.2%

(46.3–50.0)

2843

50.7%

(48.5–52.9)

1390

45.5%

(42.5–48.5)

102

34.6%

(26.9–43.2)

691

46.0%

(41.4–50.6)

 Delay of first bath

  No

4394

42.6%

(40.7–44.6)

2414

41.7%

(39.4–44.1)

1198

40.2%

(37.4–43.1)

105

47.7%

(38.5–57.1)

677

50.5%

(46.1–54.9)

  Yes

6075

57.4%

(55.4–59.3)

3329

58.3%

(55.9–60.6)

1821

59.8%

(56.9–62.6)

136

52.3%

(42.9–61.5)

 

49.5%

(45.1–53.9)

 Postnatal care within 48 h

  No

9105

85.9%

(84.5–87.1)

5038

86.8%

(85.3–88.2)

2607

84.8%

(82.3–86.9)

200

82.7%

(71.8–90.0)

1260

84.9%

(81.2–88.1)

  Yes

1364

14.1%

(12.9–15.5)

705

13.2%

(11.8–14.7)

412

15.2%

(13.1–17.7)

41

17.3%

(10.0–28.2)

206

15.1%

(11.9–18.8)

 Exclusive breastfeeding

  No

3400

33.0%

(31.6–34.4)

1832

31.3%

(29.3–33.3)

1011

35.5%

(33.1–37.9)

87

37.6%

(28.4–47.7)

470

33.8%

(30.2–37.6)

  Yes

7069

67.0%

(65.6–68.4)

3911

68.7%

(66.7–70.7)

2008

64.5%

(62.1–66.9)

154

62.4%

(52.3–71.6)

996

66.2%

(62.4–69.8)

 Post-partum contraception

  No

8835

85.3%

(84.0–86.5)

4894

85.9%

(84.2–87.4)

2562

86.8%

(85.0–88.4)

202

86.7%

(80.7–91.1)

1177

79.4%

(75.8–82.7)

  Yes

1634

14.7%

(13.5–16.0)

849

14.1%

(12.6–15.8)

457

13.2%

(11.6–15.0)

39

13.3%

([8.9–19.3)

289

20.6%

(17.3–24.2)

Background characteristics

 Ananya district

  No

7833

76.9%

(74.0–79.7)

4250

75.6%

(72.2–78.7)

2281

78.0%

(74.3–81.2)

194

84.5%

(76.8–90.0)

1108

78.8%

(74.3–82.7)

  Yes

2636

23.1%

(20.3–26.0)

1493

24.4%

(21.3–27.8)

738

22.0%

(18.8–25.7)

47

15.5%

(10.0–23.2)

358

21.2%

(17.3–25.7)

 Age

  15–19

391

4.1%

(3.5–4.9)

233

4.5%

(3.6–5.6)

98

3.8%

(2.8–5.3)

11

2.9%

(1.1–7.7)

49

3.5%

(2.5–5.0)

  20–24

4413

42.3%

(40.7–44.0)

2552

44.2%

(42.1–46.3)

1176

39.3%

(36.5–42.2)

99

45.0%

(35.4–54.9)

586

40.9%

(37.1–44.8)

  25–29

3905

35.9%

(34.2–37.5)

2120

36.3%

(34.1–38.5)

1137

35.3%

(32.7–38.0)

99

41.5%

(32.6–51.0)

549

34.4%

(30.8–38.1)

  30+

1760

17.7%

(16.4–19.0)

838

15.0%

(13.5–16.7)

608

21.5%

(19.3–23.9)

32

10.6%

(6.5–17.0)

282

21.2%

(18.0–24.7)

 Age at marriage

   < 18

4594

45.1%

(43.1–47.1)

2162

39.4%

(37.2–41.7)

1587

52.6%

(49.5–55.7)

118

52.1%

(41.7–62.2)

727

50.5%

(46.2–54.8)

  18+

5875

54.9%

(52.9–56.9)

3581

60.6%

(58.3–62.8)

1432

47.4%

(44.3–50.5)

123

47.9%

(37.8–58.3)

739

49.5%

(45.2–53.8)

 Wealth quartile

  1 (poorest)

2877

28.6%

(26.5–30.8)

1402

25.8%

(23.5–28.1)

989

34.4%

(30.9–37.9)

62

21.8%

(15.6–29.7)

424

29.0%

(24.8–33.5)

  2

2140

21.3%

(19.9–22.8)

1129

21.7%

(20.0–23.6)

670

21.8%

(19.5–24.3)

38

18.0%

(12.0–26.1)

303

19.2%

(16.3–22.6)

  3

2509

24.7%

(23.3–26.2)

1293

23.3%

(21.5–25.2)

733

24.2%

(21.8–26.7)

72

38.0%

(28.1–49.0)

411

29.2%

(25.5–33.2)

  4 (wealthiest)

2943

25.4%

(23.5–27.3)

1919

29.3%

(26.9–31.8)

627

19.7%

(17.2–22.4)

69

22.1%

(14.7–31.9)

328

22.6%

(18.8–26.9)

 Education

  None

5351

53.1%

(50.9–55.2)

2569

47.6%

(45.1–50.1)

1817

62.0%

(59.1–64.9)

112

45.8%

(36.4–55.5)

853

56.9%

(52.4–61.3)

  Primary

2705

25.9%

(24.4–27.4)

1520

26.8%

(25.0–28.7)

740

23.3%

(21.0–25.8)

68

30.2%

(23.4–38.0)

377

26.7%

(22.8–31.0)

  Secondary

2413

21.1%

(19.6–22.7)

1654

25.5%

(23.5–27.7)

462

14.7%

(12.7–16.9)

61

24.0%

(17.7–31.8)

236

16.4%

(13.3–20.0)

 Spouse’s education

  None

3237

32.4%

(30.5–34.4)

1518

28.5%

(26.4–30.8)

1132

39.5%

(36.6–42.5)

69

23.3%

(16.8–31.5)

518

34.4%

(30.8–38.2)

  Primary

3504

33.9%

(32.5–35.3)

1877

33.0%

(31.2–34.9)

1045

35.6%

(33.3–38.1)

74

33.3%

(24.5–43.4)

508

33.9%

(30.6–37.4)

  Secondary

3728

33.7%

(31.7–35.7)

2348

38.5%

(36.0–41.0)

842

24.9%

(22.1–27.8)

98

43.4%

(33.3–54.0)

440

31.7%

(27.7–35.9)

 Caste/religion

  Neither SC/ST nor Muslim

5963

56.8%

(53.7–59.8)

3507

61.1%

(57.5–64.6)

1558

51.4%

(47.8–55.1)

149

63.3%

(52.8–72.7)

749

49.8%

(44.3–55.3)

  SC/ST

2693

26.0%

(23.5–28.6)

1178

21.0%

(18.5–23.8)

991

33.2%

(29.7–36.9)

53

19.0%

(12.6–27.7)

471

31.4%

(26.7–36.5)

  Muslim

1813

17.2%

(14.6–20.3)

1058

17.8%

(14.8–21.3)

470

15.4%

(12.5–18.8)

39

17.7%

(11.4–26.5)

246

18.8%

(14.5–24.1)

 Gender of focal child

  Female

4857

46.4%

(45.0–47.9)

2663

46.3%

(44.5–48.2)

1439

47.6%

(44.8–50.4)

109

39.8%

(31.4–48.8)

646

45.4%

(41.6–49.3)

  Male

5612

53.6%

(52.1–55.0)

3080

53.7%

(51.8–55.5)

1580

52.4%

(49.6–55.2)

132

60.2%

(51.2–68.6)

820

54.6%

(50.7–58.4)

 Parity

  1

3239

30.9%

(29.5–32.4)

2036

35.0%

(33.2–36.8)

778

27.0%

(24.6,29.5)

69

29.5%

(20.5–40.5)

356

23.4%

(20.5–26.7)

  2

2979

27.7%

(26.4–29.1)

1663

28.2%

(26.6–29.8)

827

26.5%

(24.1–29.2)

72

32.2%

(23.8–42.0)

417

27.8%

(24.2–31.6)

  3+

4251

41.3%

(39.8–42.9)

2044

36.8%

(35.0–38.7)

1414

46.5%

(43.7–49.3)

100

38.3%

(29.9–47.5)

693

48.8%

(45.1–52.5)

  Age of child (months) a

5.0

(4.9–5.1)

4.9

(4.8–5.1)

5.1

(5.0–5.3)

4.9

(4.3–5.6)

5.2

(5.0–5.4)

 Previous neonatal death or stillbirth

  No

9588

91.3%

(90.4–92.2)

5336

93.0%

(91.9–93.9)

2741

89.8%

(88.1–91.4)

216

84.6%

(76.1–90.5)

1295

89.2%

(86.4–91.5)

  Yes

881

8.7%

(7.8–9.6)

407

7.0%

(6.1–8.1)

278

10.2%

(8.6–11.9)

25

15.4%

(9.5–23.9)

171

10.8%

(8.5–13.6)

 4 or more antenatal care visits

  No

8400

81.2%

(79.7–82.5)

4459

78.2%

(76.2–80.1)

2524

85.5%

(83.7–87.2)

192

80.4%

(73.0–86.2)

1225

83.7%

(81.0–86.2)

  Yes

2069

18.8%

(17.5–20.3)

1284

21.8%

(19.9–23.8)

495

14.5%

(12.8–16.3)

49

19.6%

(13.8–27.0)

241

16.3%

(13.8–19.0)

 Skilled birth attendance

  No

2826

28.0%

(26.1–30.0)

1382

24.9%

(22.8–27.1)

958

32.6%

(29.5–36.0)

65

29.3%

(21.9–38.1)

421

30.4%

(26.6–34.5)

  Yes

7643

72.0%

(70.0–73.9)

4361

75.1%

(72.9–77.2)

2061

67.4%

(64.0–70.5)

176

70.7%

(61.9–78.1)

1045

69.6%

(65.5–73.4)

 2+ CHW visits in final trimester

  No

7148

67.1%

(65.0–69.1)

4060

69.3%

(66.6–71.9)

1969

64.4%

(61.0–67.7)

159

59.9%

(50.3–68.8)

960

65.0%

(60.2–69.5)

  Yes

3321

32.9%

(30.9–35.0)

1683

30.7%

(28.1–33.4)

1050

35.6%

(32.3–39.0)

82

40.1%

(31.2–49.7)

506

35.0%

(30.5–39.8)

 Postnatal CHW visit discussing family planning

  No

9184

87.3%

(85.9–88.6)

5214

90.2%

(88.6–91.7)

2556

84.3%

(81.6–86.6)

206

85.5%

(78.7–90.4)

1208

82.4%

(78.0–86.0)

  Yes

1285

12.7%

(11.4–14.1)

529

9.8%

(8.3–11.4)

463

15.7%

(13.4–18.4)

35

14.5%

(9.6–21.3)

258

17.6%

(14.0–22.0)

aMean (95% confidence interval)

The majority of participants (78.2%) were between the ages of 20–29 and more than two-thirds had at least two children (Table 1). Nearly half of women (45.1%) were under age 18 when they married, 53.1% received no education, and 43.2% belonged to a marginalized religion/caste. Healthy newborn practices of delayed bathing (57.4%), early initiation of breastfeeding (48.2%) and exclusive breastfeeding (67.0%) were practiced by a moderate proportion of the sample, while clean cord care (25.0%), skin-to-skin care (34.6%), receiving postnatal care within 48 h (14.1%), and current post-partum contraceptive use (14.7%) were less common.

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) (Table 1). Sexual violence only was reported to be highly prevalent among mothers who did not practice EIBF (65.4% vs. 49.3% of those experiencing no IPV) and were in the third highest wealth quartile (38.0% vs. 23.3% no IPV). Women reporting both physical and sexual violence were disproportionately represented among those reporting no delayed bathing (50.5% vs. 41.7% no IPV), post-partum contraceptive use (20.6% vs. 14.1% no IPV), age 30+ (21.2% vs. 15% no IPV), under age 18 when they got married (50.5% vs. 39.4% no IPV), being in the lowest and second highest wealth quartiles (lowest quartile: 29.0% vs. 25.8% no IPV; third quartile: 29.2% vs. 23.3% no IPV), no education (56.9% vs. 47.6% no IPV), being from SC/ST caste (31.4% vs. 21.0% no IPV), three or more previous births (48.8% vs. 36.8% no IPV), less than 4 ANC (83.7% vs. 78.2% no IPV), and having had a postnatal visit to discuss family planning (17.6% vs. 9.8% no IPV).

Multivariate models to assess association between IPV and PNH practices

Adjusted analyses revealed that, compared to those who had never experienced physical or sexual IPV, women who experienced physical IPV only had higher odds of skin-to-skin care (AOR = 1.67, 95% CI = 1.42, 1.96) and delayed bathing (AOR = 1.19, 95% CI = 1.03, 1.37), but lower odds of EIBF (AOR = 0.81, 95% CI = 0.71, 0.93), and exclusive breastfeeding (AOR = 0.83, 95% CI = 0.71, 0.96) (see Table 2). Those who experienced sexual IPV only, relative to those who had experienced neither form of IPV, had lower odds of practicing EIBF (AOR = 0.52, 95% CI = 0.36, 0.76). Women who experienced both physical and sexual IPV had increased odds of currently using a modern contraceptive method (AOR = 1.35, 95% CI = 1.07, 1.71) and lower odds of delayed bathing (AOR = 0.76, 95% CI = 0.63, 0.91).
Table 2

Multivariate logistic regression models showing relationship between intimate partner violence and postnatal care behaviors and services (n = 10,469)

 

Clean cord care

Skin-to-skin care

Early initiation of breastfeeding

Delay of first bath

Postnatal care within 48 h

Exclusive breastfeeding

Post-partum contraception

Lifetime experience of intimate partner violence

 Never

REF

REF

REF

REF

REF

REF

REF

 Physical only

0.92

(0.78–1.08)

1.66

(1.41–1.96)***

0.81

(0.71–0.93)**

1.19

(1.03–1.37)*

1.16

(0.95–1.42)

0.83

(0.71–0.96)*

0.82

(0.68–0.998)*

 Sexual only

0.91

(0.58–1.41)

1.33

(0.85–2.06)

0.52

(0.36–0.76)***

0.87

(0.60–1.26)

1.22

(0.65–2.29)

0.74

(0.49–1.12)

0.91

(0.56–1.46)

 Physical and sexual

0.82

(0.66–1.02)

0.87

(0.68–1.12)

0.83

(0.67–1.01)

0.76

(0.63–0.91)**

1.14

(0.85–1.55)

0.92

(0.75–1.15)

1.35

(1.07–1.71)*

Ananya district

 No

REF

REF

REF

REF

REF

REF

 Yes

1.52

(1.24–1.85)***

1.53

(1.25–1.88)***

1.21

(1.04–1.41)*

1.53

(1.29–1.82)***

1.16

(1.00–1.34)*

1.48

(1.18–1.86)**

Age

 15–19

REF

REF

REF

REF

 20–24

0.90

(0.60–1.36)

1.44

(1.10–1.89)**

0.72

(0.50–1.04)

0.92

(0.58–1.44)

 25–29

0.77

(0.50–1.19)

1.49

(1.11–2.00)**

0.66

(0.44–0.99)*

0.91

(0.56–1.48)

 30+

0.97

(0.62–1.52)

1.49

(1.10–2.02)**

0.75

(0.50–1.11)

1.02

(0.65–1.61)

Age at marriage

  < 18

REF

REF

REF

REF

REF

REF

 18+

1.40

(1.20–1.63)***

1.15

(0.98–1.34)

1.17

(1.04–1.32)**

1.18

(1.04–1.34)**

1.14

(0.99–1.32)

1.06

(0.89–1.25)

Wealth quartile

 1 (poorest)

REF

REF

REF

REF

REF

REF

 2

0.96

(0.80–1.16)

1.08

(0.88–1.34)

0.85

(0.72–1.01)

1.13

(0.85–1.50)

1.06

(0.87–1.29)

1.12

(0.89–1.41)

 3

0.80

(0.68–0.96)*

1.27

(1.00–1.60)*

0.88

(0.74–1.04)

1.18

(0.91–1.54)

0.92

(0.76–1.11)

1.38

(1.11–1.72)**

 4 (wealthiest)

0.92

(0.71–1.18)

1.30

(1.04–1.62)*

0.89

(0.73–1.08)

0.90

(0.67–1.22)

0.84

(0.69–1.03)

1.43

(1.13–1.82)**

Education

 None

REF

REF

REF

 Primary

0.95

(0.80–1.12)

1.16

(1.02–1.34)*

1.04

(0.89–1.20)

 Secondary

0.92

(0.73–1.15)

0.85

(0.73–1.00)

0.98

(0.81–1.20)

Spouse’s education

 None

REF

REF

REF

 Primary

0.85

(0.71–1.03)

0.94

(0.80–1.09)

0.84

(0.72–0.98)*

 Secondary

0.72

(0.59–0.89)**

1.01

(0.85–1.20)

0.92

(0.77–1.10)

Caste/religion

 Neither SC/ST nor Muslim

REF

REF

REF

REF

 SC/ST

1.04

(0.85–1.27)

0.94

(0.81–1.11)

0.85

(0.71–1.02)

1.00

(0.80–1.24)

 Muslim

0.79

(0.62–1.00)

0.77

(0.63–0.95)*

1.09

(0.91–1.30)

0.59

(0.45–0.78)***

Gender of focal child

 Female

REF

 Male

1.17

(0.99–1.39)

Parity

 1

REF

REF

REF

REF

REF

 2

0.97

(0.83–1.13)

1.29

(1.10–1.51)**

1.05

(0.90–1.23)

1.25

(1.06–1.47)**

1.75

(1.37–2.25)***

 3+

0.91

(0.77–1.09)

1.26

(1.05–1.52)*

1.08

(0.90–1.29)

1.18

(1.01–1.37)*

3.39

(2.61–4.40)***

 Age of child (months)1

0.97

(0.95–0.99)*

0.98

(0.96–0.999)

0.78

(0.77–0.80)

1.08

(1.06–1.11)***

Previous neonatal death or stillbirth

 No

REF

REF

REF

 Yes

0.88

(0.68–1.13)

0.66

(0.54–0.82)

0.88

(0.71–1.08)

4 or more antenatal care visits

 No

REF

REF

REF

REF

REF

 Yes

0.82

(0.67–1.01)

1.16

(0.999–1.35)

1.32

(1.05–1.66)*

0.81

(0.68–0.97)*

1.23

(1.01–1.49)*

Skilled birth attendance

 No

REF

REF

REF

REF

REF

REF

REF

 Yes

0.81

(0.70–0.94)**

1.54

(1.29–1.84)***

1.19

(1.03–1.37)*

1.92

(1.66–2.21)***

1.82

(1.37–2.41)***

1.21

(1.04–1.39)*

1.38

(1.12–1.70)**

2+ CHW visits in final trimester

 No

REF

REF

REF

REF

 Yes

1.27

(1.07–1.51)**

1.26

(1.11–1.44)***

4.22

(3.46–5.15)***

0.88

(0.72–1.06)

Postnatal CHW visit discussing family planning

 No

N/A

N/A

N/A

N/A

N/A

N/A

REF

 Yes

N/A

N/A

N/A

N/A

N/A

N/A

2.34

(1.88–2.92)***

Models show adjusted odds ratios (95% confidence intervals), and include intimate partner violence as well as any covariates significant at the p < 0.20 level in bivariate models

*p < 0.05

**p < 0.01

***p < 0.001

1Mean (95% confidence interval)

Based on previous work and observed effects in this study, current post-partum contraceptive use was further explored in post-hoc analyses [34]. A multinomial regression assessed the association between IPV and specific types of contraception (sterilization [male or female], pills, condoms, or “other”, which included IUD and injectable contraception), and included all covariates used in the main multivariate model for current modern contraception.

Post-hoc exploratory analysis identified that of the 1274 women using post-partum modern contraceptives, 119 (9.3%) 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 (adjusted relative risk ratio [ARRR] = 0.53, 95% CI = 0.32, 0.87, p = 0.01) and women experiencing both physical and sexual IPV were twice as likely to be using condoms (ARRR = 2.04, 95% CI = 1.43, 2.92, p < 0.001) (Table 3). Different patterns of association of type of IPV with sterilization and with other forms of contraception were not observed.
Table 3

Post-hoc multinomial regression model assessing relationship between intimate partner violence and type of current post-partum contraception use

 

Current postpartum contraception

Sterilization (male or female)

Pill

Condom

Other^

Lifetime experience of IPV

 No IPV ever

REF

REF

REF

REF

 Physical IPV only

0.89 (0.70–1.13)

0.53 (0.32–0.87)*

0.95 (0.67–1.33)

0.60 (0.27–1.36)

 Sexual IPV only

0.97 (0.49–1.92)

1.00 (0.37–2.67)

0.94 (0.47–1.89)

0.25 (0.05–1.23)

 Physical and sexual IPV

1.13 (0.82–1.55)

1.17 (0.64–2.13)

2.04 (1.43–2.92)***

1.23 (0.52–2.90)

Multinomial regression model shows adjusted relative risk ratios (95% confidence intervals), and adjusts for all covariates shown in the post-partum contraception model in Table 2. Reference category is no current contraception

^Includes IUD and injectables

*p < 0.05

***p < 0.001

Discussion

Findings from this study indicate that almost half of women in Bihar, India have experienced physical and/or sexual violence from their husband. One in six women reported sexual violence, most often accompanied by physical violence. Associations between IPV and PNH practices were found, including healthy breastfeeding practices, skin to skin care, delayed bathing, and postpartum contraception use, but suggest a complex risk pattern across types of IPV.

The National Family Health Survey-4 (NFHS-4) conducted in 2015/16 found a similar rate of spousal violence among ever-married women in Bihar (43.2%) [17]. Sexual violence was (16.3%) was also common, with only 2% of women experiencing sexual violence without physical violence. This prevalence reflects that reported for Bihar in the NFHS-3 conducted in 2005/6 (NFHS-4 data not yet available) [11].

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 [28, 32, 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 [27, 28, 31, 32, 4044].

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 [45]. In contrast with these findings, women experiencing a combination of physical and sexual violence appear to be less able to enact these same PNH behaviors. Previous research in Brazil has documented higher risk of postpartum depression associated with the co-occurrence of multiple forms of violence during pregnancy [46]. This previous work may shed some light on why the present study observed lower rates of PNH behaviors among women experiencing multiple forms of violence. The opposing effects seen in this sample for these PNH practices for different types of IPV may have important implications for understanding how the context of IPV contributes to health practices and warrant further study. Further work in this area should consider assessment of motivations for and barriers to these practices in the context of IPV, particularly in the case of delayed bathing which is affected by both culture and access to soap and water, where skin-to-skin contact requires primarily bodily resources, such as time and energy, from the mother.

Likelihood 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 [34]. Raj et al. found that in a situation where women have little control over sex (i.e. experience forced sex), they are actually more likely to use contraception compared to women not experiencing forced sex, suggesting that they may be using contraception to gain greater control of their reproductive health in the face of loss of control over sex [23, 47]. This previous study was not limited to contraception use during the postpartum period [34]. Further research is needed to confirm and explore the results found here, and to understand if this is a changing dynamic around contraception use in India or if this is specific to postpartum use.

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 [38]. The Ananya program includes the use of community health workers to conduct household visits during pregnancy to provide basic services and facilitate access to clinical care, an intervention model upon which it might be possible to build in services to address IPV in relation to postnatal care practices.

Consideration 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.

Conclusion

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.

Abbreviations

ANC: 

Antenatal care

AOR: 

Adjusted odds ratio

ARRR: 

Adjusted relative risk ratio

CHW: 

Community health worker

DHS: 

Demographic and Health Surveys

EIBF: 

Early initiation of breastfeeding

IPV: 

Intimate partner violence

IUD: 

Intrauterine device

PNH: 

Postnatal health

SBA: 

Skilled birth attendant

SC/ST: 

Scheduled caste/scheduled tribe

Declarations

Acknowledgements

We would like to acknowledge and thank the participants, staff and partners of the Ananya study in Bihar, India, for making available these data for analyses.

Funding

This work was funded by the Bill and Melinda Gates Foundation (BMGF). BMGF staff (Katherine Hay, Diva Dhar, Yamini Atmavilas) were involved in the development of this study and the generation of this manuscript, and are recognized as coauthors. In their roles with BMGF, they were involved with the design and conduct of the larger Ananya evaluation study design from which data for this study were obtained. They provided some oversight of data collection and management, and they provided input into analyses undertaken for this manuscript. They assisted with the interpretation of this paper and reviewed and approved this final manuscript.

Availability of data and materials

The data that support the findings of this study are available from the Bill & Melinda Gates Foundation (BMGF) but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of BMGF.

Authors’ contributions

SB was involved in the analysis and interpretation of data and led the writing and revisions of the manuscript. LM conducted the analysis and was highly involved in the interpretation of the results and manuscript writing. JS was involved in the analysis, interpretation of results and manuscript development. YA, DD, and KH were involved in the design and implementation of the study, provided input on the analyses and interpretation of results, and were involved in the generation of the manuscript. AR led the conceptualization, analysis, interpretation of results, writing, and revisions related to this manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Ethical approval for the original evaluation study was provided by India’s Health Ministry Screening Committee (#TRC-IEC-104/11). Ethical approval for this analysis was provided by the University of California, San Diego (#150746). All data were collected by trained female study staff, subsequent to acquisition of written informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Center on Gender Equity and Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA, USA
(2)
Bill and Melinda Gates Foundation, New Delhi, India

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