September 2005, Vol. 11, No. 3

Violence Against Women
Physical Abuse Common During Pregnancy in South Asia, Studies Find

Population Council researchers recently completed studies in Pakistan and Nepal of attitudes and behaviors surrounding violence against women during pregnancy. These investigations were some of the first of their kind in South Asia. They probed the level of awareness of domestic violence among obstetrician/gynecologists (OB/GYNs) in Karachi, Pakistan, and of OB/GYNs, assistant nurse midwives, and traditional birth attendants in Kathmandu, Nepal. Postpartum women in Karachi and Kathmandu were surveyed to augment knowledge about the scope, context, and consequences of violence faced by pregnant women. In a separate study, men in Karachi were interviewed about domestic violence. Although preliminary and limited to two urban areas, the studies suggest a high level of physical abuse during pregnancy and provide some empirical basis for developing realistic interventions to protect the lives of women and their children.

In addition to infringing on women’s human rights, domestic violence poses significant risks to women’s health, including their reproductive health. During the stress of pregnancy, domestic violence may begin or intensify, harming the mother as well as the fetus. Violence during pregnancy has been associated with maternal death; pregnancy complications, including placental abruption, premature rupture of membranes, and preterm birth; and adverse outcomes, including abortion, miscarriage, and low birthweight.

Obstetrician Fariyal F. Fikree spearheaded the studies in Pakistan and Nepal. Fikree, now at the Population Reference Bureau, was Population Council director of regional health programs in Cairo, Egypt. In each country, researchers interviewed 100 OB/GYNs to assess their awareness regarding the magnitude of violence against women, violence during pregnancy, and the effects of violence on maternal and fetal health. The study also explored providers’ opinions on potential interventions and barriers to these programs. In both cities, the vast majority of OB/GYNs are women.

To supplement the information collected from these providers, researchers also interviewed 300 women in each city who had recently given birth in a large public maternity hospital. Investigators assessed their awareness of and attitudes toward violence against women (particularly violence during pregnancy), their care-seeking behavior for injuries associated with domestic violence, and their attitudes toward the responses of physicians or health care workers. In Kathmandu, where home deliveries are common, investigators also interviewed 50 women who delivered their babies at home, 50 assistant nurse midwives, and ten traditional birth attendants.

Obstetricians’ awareness
Obstetricians in both locations and other birth attendants in Kathmandu were nearly universally aware of severe pregnancy complications caused by physical abuse. The majority of obstetricians interviewed believed that more than 30 percent of women in Pakistan and Nepal are the victims of domestic violence. But the majority of OB/GYNs thought that the prevalence of domestic abuse in their own practices was less than 10 percent. Types of physical abuse mentioned by doctors included beating, slapping, kicking, and pulling hair. Injuries mentioned included bruises, cuts, burns, and vaginal trauma.

In both locations, about three-quarters of obstetricians agreed that a health care provider’s role includes helping domestic violence victims. In Kathmandu, 77 percent of obstetricians approved of routinely screening patients for signs of abuse, and 29 percent said they regularly screened their antenatal patients. In Karachi, 47 percent of obstetricians were favorably inclined to routinely screen patients, though only 3 percent reported routine screening for domestic violence at antenatal visits (see table). The main reasons given for not routinely screening patients in both locations included a lack of training in domestic violence issues, a lack of time, and not having a solution to the problem. The majority of providers expressed interest in dealing with domestic violence and suggested that it would be important to receive training to be able to counsel women as part of antenatal care.

Women’s experiences
Nearly one-quarter of the women interviewed in Karachi and one-third of the women interviewed in Kathmandu reported some form of physical abuse during the last pregnancy or earlier ones. Twenty-two percent of women in Karachi said they were slapped and 11 percent of them mentioned forced sexual intercourse. In Kathmandu, 32 percent of women reported being slapped and 22 percent mentioned forced sexual intercourse. “Obstetricians were shocked that the level of physical and sexual abuse during pregnancy was as high as women reported,” says Fikree.

Only 10 percent of women in Karachi and Kathmandu who were injured by domestic violence sought help. Among those who sought assistance, most women were looking for someone to “mediate on their behalf” or sought help “to prevent wife beating.” Women in both locations felt uncomfortable discussing domestic violence with health care providers and also felt that providers were uninterested and uncaring.

However, a little over half of the women interviewed in Karachi and nearly all the women interviewed in Kathmandu thought that an antenatal visit was an appropriate time for health care providers to routinely screen for domestic violence. In Karachi, women overwhelmingly identified doctors as the preferred health care provider to make this type of inquiry. In Kathmandu, women were about evenly split on whether a nurse or a doctor should make the inquiry.

The cycle of violence
“Previous research has suggested that exposure to violence in childhood—both witnessing and enduring violence—was a root cause of domestic violence in adulthood,” says Fikree. In 1996, for example, Fikree and her colleagues interviewed 176 men in Karachi about their attitudes toward wife abuse and examined predictors for the risk of physical abuse. They found that 49 percent of men reported physically abusing their wives. Among these admitted abusers, 55 percent said they had been beaten as a child and 65 percent had witnessed their mother being beaten.

To follow up on these findings, the researchers asked the women in Karachi and Kathmandu about the effects of domestic violence on their children. In Karachi, 49 percent of women said that their children had witnessed them being abused. Half of those children were physically abused as well. In Kathmandu, 44 percent of women said that their children had witnessed them being abused. Forty-eight percent of those children were also physically abused. “How many of these abused children will go on to become abusers?” asks Fikree.

Proposed intervention strategies
Raising awareness about the enormity of physical abuse during pregnancy might motivate obstetricians to institute routine domestic violence screening. The investigators believe that interventions by the medical community, such as routine screening by obstetricians during antenatal visits, are necessary and will be welcomed by women. Appropriate counseling and referral systems must be instituted prior to implementing routine screening programs. Given the findings about the level of child abuse and the evidence that abused children often go on to become abusers, program managers should develop separate interventions to stop child abuse. “Detecting and preventing child abuse will be a key step in breaking the cycle of violence,” says Fikree.

Sources
Fikree, Fariyal F., Sadiqua N. Jafarey, Razia Korejo, Anjum Afshan, and Jill M. Durocher. “Intimate partner violence before and during pregnancy: Experiences of postpartum women in Karachi, Pakistan,” Journal of Pakistan Medical Association, forthcoming.

Deuba, Arzu Rana and Pinky Singh Rana. 2005. A Study on Linkages Between Domestic Violence and Pregnancy. Kathmandu, Nepal: SAMANTA— Institute for Social and Gender Equality.

Fikree, Fariyal F., Junaid A. Razzak, and Jill Durocher. 2005. “Attitudes of Pakistani men to domestic violence: A study from Karachi, Pakistan,” International Journal on Men’s Health and Gender 2(1): 49–58.

Fikree, Fariyal F., Sadiqua N. Jafarey, Razia Korejo, Ambareen Khan, and Jill M. Durocher. 2004. “Pakistani obstetricians’ recognition of and attitude towards domestic violence screening,” International Journal of Gynecology and Obstetrics 87(1): 59–65.

Fikree, Fariyal F., Sadiqua N. Jafarey, Razia Korejo, Ambareen Khan, Anjum Afshan, and Jill M. Durocher. 2003. “Obstetricians’ and women’s perspectives: A case study of domestic violence from Pakistan.” New York: Population Council.

Outside funding
Aga Khan University, the William and Flora Hewlett Foundation, and the John D. and Catherine T. MacArthur Foundation

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See Also

• "Gender and family dynamics/Violence against women," overview (full text)

• "Safe motherhood and postpartum care: Gender-based violence during pregnancy," overview (full text)