Mariano Salazar

Ending intimate partner violence after pregnancy: findings from a community-based longitudinal study in Nicaragua.

BackgroundAlthough reducing intimate partner violence (IPV) is a pervasive public health problem, few longitudinal studies in developing countries have assessed ways to end such abuse. To this end, this paper aims to analyze individual, family, community and societal factors that facilitate reducing IPV.MethodsA longitudinal population-based study was conducted in León, Nicaragua at a demographic surveillance site. Women (n = 478) who were pregnant between 2002 and 2003 were interviewed, and 398 were found at follow-up, 2007. Partner abuse was measured using the WHO Multi-country study on womens health and domestic violence questionnaire. Womens socio demographic variables, perceived emotional distress, partner control, social resources, womens norms and attitudes towards IPV and help-seeking behaviours were also assessed. Ending of abuse was defined as having experienced any abuse in a lifetime or during pregnancy but not at follow-up. Crude and adjusted odds ratios were applied.ResultsOf the women exposed to lifetime or pregnancy IPV, 59% reported that their abuse ended. This finding took place in a context of a substantial shift in womens normative attitudes towards not tolerating abuse. At the family level, no or diminishing partner control [ORadj 6.7 (95%CI 3.5-13)] was associated with ending of abuse. At the societal level, high or improved social resources [ORadj 2.0 (95%CI 1.1.-3.7)] were also associated with the end of abuse.ConclusionA considerable proportion of women reported end of violence. This might be related to a favourable change in womens norms and attitudes toward gender roles and violence and a more positive attitude towards interventions from people outside their family to end abuse. Maintaining and improving social resources and decreasing partner control and isolation are key interventions to ending abuse. Abuse inquiring may also play an important role in this process and must include health care providers training and a referral system to be more effective. Interventions at the community level are crucial to reducing partner violence.

Intimate partner violence and early child growth: a community-based cohort study in Nicaragua

BackgroundThis study analyses whether a mother’s exposure to different forms of Intimate Partner Violence (IPV) during pregnancy was associated with the index child linear growth, and whether these associations were modified by the gender of the child.MethodsA pregnancy cohort of 478 women in León, Nicaragua, resulted in 461 live births. From this group, 81% (375/461) children were available for anthropometric follow-up at 40 to 46 months. Analysis of covariance (ANCOVA) was used to assess the association between IPV and height-for-age Z-scores, adjusting for confounding factors.ResultsSixty-three percent (236/375) of the mothers had been exposed to some form of IPV during pregnancy (emotional, physical, sexual or controlling behavior). After adjustment for confounding factors, maternal exposure to any IPV during pregnancy was associated with 0.24 lower mean height-for-age Z-scores (p = 0.02). A separate analysis of each IPV type showed that emotional, physical or sexual IPV during pregnancy were not significantly associated with lower mean height-for-age Z-scores, whereas ever exposure to controlling behavior by the father of the child was related to 0.29 lower mean height-for-age Z-scores (p < 0.01) When stratified by gender, these associations remained significant only for young girls.ConclusionsThis study has contributed to the growing amount of evidence pointing to the pervasive effect of different forms of IPV on child health. Our study highlights the relevance of maternal autonomy for linear child growth, especially for young girls in the Nicaraguan context.

Violence against women and unintended pregnancies in Nicaragua: A population-based multilevel study

BackgroundDespite an increased use of contraceptive methods by women, unintended pregnancies represent one of the most evident violations of women’s sexual and reproductive rights around the world. This study aims to measure the association between individual and community exposure to different forms of violence against women (physical/sexual violence by the partner, sexual abuse by any person, or controlling behavior by the partner) and unintended pregnancies.MethodsData from the 2006/2007 Nicaraguan Demographic and Health Survey were used. For the current study, 5347 women who reported a live birth in the five years prior to the survey and who were married or cohabitating at the time of the data collection were selected. Women’s exposure to controlling behaviors by their partners was measured using six questions from the WHO Multi-Country Study on Women’s Health and Domestic Violence against Women.Area-level variables were constructed by aggregating the individual level exposures to violence into an exposure measurement of the municipality as a whole (n = 142); which is the basic political division in Nicaragua. Multilevel logistic regression was used to analyze the data.ResultsIn total, 37.1% of the pregnancies were reported as unintended. After adjusting for all variables included in the model, individual exposure to controlling behavior by a partner (AOR = 1.28, 95% CrI = 1.13–1.44), ever exposure to sexual abuse (AOR = 1.31, 95% CrI = 1.03–1.62), and ever exposure to physical/sexual intimate partner violence (AOR = 1.44, 95% CrI = 1.24–1.66) were significantly associated with unintended pregnancies. Women who lived in municipalities in the highest tertile of controlling behavior by a partner had 1.25 times higher odds of reporting an unintended pregnancy than women living in municipalities in the lowest tertile (AOR = 1.25, 95% CrI = 1.03–1.48).ConclusionsNicaraguan women often experience unintended pregnancies, and the occurrence of unintended pregnancies is significantly associated with exposure to different forms of violence against women at both the individual and the municipality level. National policies aiming to facilitate women’s ability to exercise their reproductive rights must include actions aimed at reducing women’s exposures to violence against women.

The Supportive Process for Ending Intimate Partner Violence After Pregnancy The Experience of Nicaraguan Women

This grounded theory study found that Nicaraguan mothers exposed to intimate partner violence (IPV) during pregnancy eventually acted to protect their children and themselves. They experienced ending abuse as an empowerment process characterized by a cognitive change in women’s attitudes toward partner abuse and the emergence of help-seeking strategies that lead to ending violence with or without ending the relationship. This process was facilitated by a supportive environment that challenged abusive behaviors as well as being asked about abuse during their last pregnancy. Although environmental changes can facilitate ending abuse, Nicaragua’s public institutions must be strengthened to reach women in need.

Bypassing health facilities for childbirth: a multilevel study in three districts of Gujarat, India

Background Bypassing available facilities for childbirth has important implications for maternal health service delivery and human resources within a health system. The results are the additional expenses imposed on the woman and her family, as well as the inefficient use of health system resources. Bypassing often indicates a lack of confidence in the care provided by the facility nearest to the mother, which implies a level of dysfunctionality that the health system needs to address. Over the past decade, India has experienced a steep rise in the proportion of facility births. The initiation of programs promoting facility births resulted in a rise from 39% in 2005 to 85% in 2014. There have been no reports on bypassing facilities for childbirth from India. In the context of steeply rising facility births, it is important to quantify the occurrence of and study the relative contributions of maternal characteristics and facility functionality to bypassing. Objectives 1) To determine the extent of bypassing health facilities for childbirth among rural mothers in three districts of Gujarat, India, 2) to identify associations between the functionality of an obstetric care (OC) facility and it being bypassed, and 3) to assess the relative contribution of maternal and facility characteristics to bypassing. Design A cross-sectional survey of 166 public and private OC facilities reporting ≥30 births in the 3 months before the survey was conducted in three purposively selected districts (Dahod, Sabarkantha, and Surendranagar) in the state of Gujarat, India. Besides information on each facility, data from 946 women giving birth at these facilities were also gathered. Data were analyzed using a multilevel mixed-effects logistic regression model. Results Off all mothers, 37.7% bypassed their nearest facility for childbirth. After adjusting for maternal characteristics, for every one-unit increase in the facilitys emergency obstetric care (EmOC) signal functions, the odds of bypassing a facility for childbirth decreased by 37% (adjusted odds ratio [AOR] 0.63, 95% confidence interval [CI]: 0.53–0.76). Conclusions This study shows that independent of maternal characteristics, in our setting, women will bypass obstetric facilities that are not adequately functional, and travel further to others that are more functional. It is important that the health system should focus on facility functionality, especially in the context of sharply rising hospital births.Background Bypassing available facilities for childbirth has important implications for maternal health service delivery and human resources within a health system. The results are the additional expenses imposed on the woman and her family, as well as the inefficient use of health system resources. Bypassing often indicates a lack of confidence in the care provided by the facility nearest to the mother, which implies a level of dysfunctionality that the health system needs to address. Over the past decade, India has experienced a steep rise in the proportion of facility births. The initiation of programs promoting facility births resulted in a rise from 39% in 2005 to 85% in 2014. There have been no reports on bypassing facilities for childbirth from India. In the context of steeply rising facility births, it is important to quantify the occurrence of and study the relative contributions of maternal characteristics and facility functionality to bypassing. Objectives 1) To determine the extent of bypassing health facilities for childbirth among rural mothers in three districts of Gujarat, India, 2) to identify associations between the functionality of an obstetric care (OC) facility and it being bypassed, and 3) to assess the relative contribution of maternal and facility characteristics to bypassing. Design A cross-sectional survey of 166 public and private OC facilities reporting ≥30 births in the 3 months before the survey was conducted in three purposively selected districts (Dahod, Sabarkantha, and Surendranagar) in the state of Gujarat, India. Besides information on each facility, data from 946 women giving birth at these facilities were also gathered. Data were analyzed using a multilevel mixed-effects logistic regression model. Results Off all mothers, 37.7% bypassed their nearest facility for childbirth. After adjusting for maternal characteristics, for every one-unit increase in the facilitys emergency obstetric care (EmOC) signal functions, the odds of bypassing a facility for childbirth decreased by 37% (adjusted odds ratio [AOR] 0.63, 95% confidence interval [CI]: 0.53-0.76). Conclusions This study shows that independent of maternal characteristics, in our setting, women will bypass obstetric facilities that are not adequately functional, and travel further to others that are more functional. It is important that the health system should focus on facility functionality, especially in the context of sharply rising hospital births.

Negotiating Masculinity, Violence, and Responsibility: A Situational Analysis of Young Nicaraguan Men’s Discourses on Intimate Partner and Sexual Violence

This situational analysis study aims to explore the discourses that young Nicaraguan men use in their understanding of male intimate partner violence (IPV) and sexual abuse toward women. Six urban and 8 rural focus group discussions including 91 men were conducted. Positional maps were used to articulate the positions taken in the data within 2 continuums of variation representing men’s reasoning around control over women and men’s responsibility for IPV and sexual abuse (SA). Nicaraguan men’s discourses ranged from challenging gender inequality, IPV, and SA to supporting the patriarchal gender order. A key finding shows that a discourse supporting gender equality and men’s full responsibility for IPV and SA is fighting to achieve recognition in this setting.

Exposure to intimate partner violence reduces the protective effect that women’s high education has on children’s corporal punishment: a population-based study

Background Previous studies have shown that womens education is protective against corporal punishment (CP) of children. However, the effect that womens exposure to intimate partner violence (IPV) has on the association between womens education and childrens CP has not been studied. Objective To understand how the interaction between womens exposure to IPV and their education level influences the occurrence of childrens CP at the household level. Methods We selected 10,156 women who had at least one child less than 16 years old from cross-sectional data from the 2006–2007 Nicaraguan Demographic and Health Survey. Childrens CP was defined as the punishment of children by slapping them, hitting them with a fist, or hitting them with a rope, belt, stick, or other object. IPV was measured by using a conflict tactic scale. The WHO Self-Reporting Questionnaire 20 (SRQ-20) was used to assess the womens mental health. We computed adjusted risk ratios (ARR) and 95% confidence intervals (CI) using Poisson regression with a robust variance estimator. Results Womens exposure to IPV was associated with a 10–17% increase in the risk of childrens CP. IPV and childrens CP were associated with impaired womens mental health. Womens lifetime exposure to emotional IPV and controlling behavior by a partner significantly decreased the protective effect from womens high education level on childrens CP. When women were exposed to emotional IPV, the protective effect from having a college education decreased from ARR=0.61 (95% CI 0.47–0.80) to ARR=0.98 (95% CI 0.80–1.19). A similar pattern was found among women exposed to controlling behavior by a partner, the protective effect decreased from ARR=0.71 (95% CI 0.53–0.90) to ARR=0.86 (95% CI 0.70–1.06). Conclusion This study shows how significant gains in one positive social determinant of childrens well-being can be undermined when it interacts with mens violence toward women. Policies that aim to end childrens CP must include actions to end womens exposure to IPV.Background Previous studies have shown that womens education is protective against corporal punishment (CP) of children. However, the effect that womens exposure to intimate partner violence (IPV) has on the association between womens education and childrens CP has not been studied. Objective To understand how the interaction between womens exposure to IPV and their education level influences the occurrence of childrens CP at the household level. Methods We selected 10,156 women who had at least one child less than 16 years old from cross-sectional data from the 2006-2007 Nicaraguan Demographic and Health Survey. Childrens CP was defined as the punishment of children by slapping them, hitting them with a fist, or hitting them with a rope, belt, stick, or other object. IPV was measured by using a conflict tactic scale. The WHO Self-Reporting Questionnaire 20 (SRQ-20) was used to assess the womens mental health. We computed adjusted risk ratios (ARR) and 95% confidence intervals (CI) using Poisson regression with a robust variance estimator. Results Womens exposure to IPV was associated with a 10-17% increase in the risk of childrens CP. IPV and childrens CP were associated with impaired womens mental health. Womens lifetime exposure to emotional IPV and controlling behavior by a partner significantly decreased the protective effect from womens high education level on childrens CP. When women were exposed to emotional IPV, the protective effect from having a college education decreased from ARR=0.61 (95% CI 0.47-0.80) to ARR=0.98 (95% CI 0.80-1.19). A similar pattern was found among women exposed to controlling behavior by a partner, the protective effect decreased from ARR=0.71 (95% CI 0.53-0.90) to ARR=0.86 (95% CI 0.70-1.06). Conclusion This study shows how significant gains in one positive social determinant of childrens well-being can be undermined when it interacts with mens violence toward women. Policies that aim to end childrens CP must include actions to end womens exposure to IPV.

Questions about intimate partner violence should be part of contraceptive counselling: findings from a community-based longitudinal study in Nicaragua

Background and methodology The study aim was to examine whether exposure to intimate partner violence (IPV) was associated with reversible contraceptive use in ever-pregnant partnered women. The authors conducted a longitudinal panel study in León municipality, Nicaragua. At baseline (2002–2003), 478 pregnant women were interviewed and 398 were available for questioning about contraceptive use 40–47 months after childbirth. IPV was assessed at baseline and follow-up, with women classified as never abused, ending abuse, continued abuse or new abuse. Reversible contraceptive use was defined as women using any form of contraception apart from sterilisation. Adjusted odds ratios (AORs) were used to assess the association between reversible contraceptive use, IPV patterns and IPV exposures at follow-up. Results Eighty percent of the women were not pregnant and with a partner at follow-up. Half were using reversible contraceptives and 28% were sterilised. Women exposed to a continued abuse pattern (AOR 2.50, 95% CI 11.04–5.99), and those exposed to emotional (AOR 2.80, 95% CI 1.32–5.95), physical (AOR 3.60, 95% CI 1.15–11.10) or any IPV at follow-up (AOR 2.59, 95% CI 1.24–5.40) had higher odds of reversible contraceptive use than those not exposed, even after adjusting for demographic factors. No significant differences in the type of reversible contraceptive used were found between women exposed or not to IPV. Discussion and conclusions IPV exposure was associated with more reversible contraceptive use. Abuse inquiring at health facilities providing contraceptives should be implemented to identify women exposed to IPV and provide adequate support.

Bypassing health facilities for childbirth in the context of the JSY cash transfer program to promote institutional birth : A cross-sectional study from Madhya Pradesh, India

Bypassing health facilities for childbirth can be costly both for women and health systems. There have been some reports on this from Sub-Saharan African and from Nepal but none from India. India has implemented the Janani Suraksha Yojana (JSY), a large national conditional cash transfer program which has successfully increased the number of institutional births in India. This paper aims to study the extent of bypassing the nearest health facility offering intrapartum care in three districts of Madhya Pradesh, India, and to identify individual and facility determinants of bypassing in the context of the JSY program. Our results provide information to support the optimal utilization of facilities at different levels of the healthcare system for childbirth. Data was collected from 96 facilities (74 public) and 720 rural mothers who delivered at these facilities were interviewed. Multilevel logistic regression was used to analyze the data. Facility obstetric care functionality was assessed by the number of emergency obstetric care (EmOC) signal functions performed in the last three months. Thirty eighth percent of the mothers bypassed the nearest public facility for their current delivery. Primiparity, higher education, arriving by hired transport and a longer distance from home to the nearest facility increased the odds of bypassing a public facility for childbirth. The variance partition coefficient showed that 37% of the variation in bypassing the nearest public facility can be attributed to difference between facilities. The number of basic emergency obstetric care signal functions (AOR = 0.59, 95% CI 0.37–0.93), and the availability of free transportation at the nearest facility (AOR = 0.11, 95% CI 0.03–0.31) were protective factors against bypassing. The variation between facilities (MOR = 3.85) was more important than an individual’s characteristics to explain bypassing in MP. This multilevel study indicates that in this setting, a focus on increasing the level of emergency obstetric care functionality in public obstetric care facilities will allow more optimal utilization of facilities for childbirth under the JSY program thereby leading to better outcomes for mothers.

Who is using the morning-after pill? Inequalities in emergency contraception use among ever partnered Nicaraguan women; findings from a national survey

IntroductionFew studies have described the inequalities in hormonal emergency contraception (HEC) use in developing countries. Thus, the main aim of this manuscript is to study socio-demographic inequalities in HEC use among Nicaraguan women, and to study if inequalities in HEC use arise from exposure to different forms of intimate partner violence (IPV).MethodsData from a national cross-sectional study conducted from 2006 to 2007 was used. This study included data from 8284 ever partnered, non-sterilized women. Separate multivariate logistic regressions with each form of IPV were conducted to study how different forms of IPV were associated with HEC. Women´s age, residency, education, socioeconomic status, parity, and current use of reversible contraception were included in the multivariate logistic regressions to obtain adjusted odds ratios showing inequalities in HEC use.ResultsSix percent of the women had ever used HEC (95% CI 5.1-6.9). Multivariate analyses showed that urban residency, higher education, and higher socioeconomic status were significantly associated with higher odds of ever using HEC, and age was associated with decreased odds of HEC use. A key finding of this study is that after controlling for socio-demographic factors, the odds of using HEC were higher for those women ever exposed to emotional IPV (AOR 1.58, 95% CI 1.16-2.00), physical IPV (AOR 1.82, 95% CI 1.30-2.55), sexual IPV (AOR 1.63, 95% CI 1.06-2.52), and controlling behavior by partner (AOR 1.51 95% CI 1.13-2.00) than those not exposed.ConclusionsThis study provides sound evidence supporting the hypothesis that there are inequalities in HEC use even in countries where inequalities in use to other forms of contraceptive technology has been reduced. HEC use among Nicaraguan women is strongly influenced by individual factors such as age, residency, educational level, socioeconomic status, and exposure to different forms of IPV. It is paramount that actions are taken to diminish these gaps.