Michael A. Koenig

Individual and Contextual Determinants of Domestic Violence in North India

OBJECTIVES We examined individual- and community-level influences on domestic violence in Uttar Pradesh, North India. METHODS Multilevel modeling was used to explore domestic violence outcomes among a sample of 4520 married men. RESULTS Recent physical and sexual domestic violence was associated with the individual-level variables of childlessness, economic pressure, and intergenerational transmission of violence. A community environment of violent crime was associated with elevated risks of both physical and sexual violence. Community-level norms concerning wife beating were significantly related only to physical violence. CONCLUSIONS Important similarities as well as differences were evident in risk factors for physical and sexual domestic violence. Higher socioeconomic status was found to be protective against physical but not sexual violence. Our results provide additional support for the importance of contextual factors in shaping womens risks of physical and sexual violence.

Domestic violence in rural Uganda: evidence from a community-based study

Although domestic violence is an increasing public health concern in developing countries, evidence from representative, community-based studies is limited. In a survey of 5109 women of reproductive age in the Rakai District of Uganda, 30% of women had experienced physical threats or physical abuse from their current partner--20% during the year before the survey. Three of five women who reported recent physical threats or abuse reported three or more specific acts of violence during the preceding year, and just under a half reported injuries as a result. Analysis of risk factors highlights the pivotal roles of the male partners alcohol consumption and his perceived human immunodeficiency virus (HIV) risk in increasing the risk of male against female domestic violence. Most respondents--70% of men and 90% of women--viewed beating of the wife or female partner as justifiable in some circumstances, posing a central challenge to preventing violence in such settings.

Prevalence of and Risk Factors for Intimate Partner Violence in China

OBJECTIVES We estimated the prevalence of and risk factors for intimate partner violence in China. METHODS Our cross-sectional, comparative prevalence study used a face-to-face survey of randomly selected women attending an urban outpatient gynecological clinic at a major teaching hospital in Fuzhou, China. Multiple logistic regression models were used to assess risk factors for intimate partner violence. RESULTS Of the 600 women interviewed, the prevalence of lifetime intimate partner violence and violence taking place within the year before the interview was 43% and 26%, respectively. For lifetime intimate partner violence, partners who had extramarital affairs and who refused to give respondents money were the strongest independent predictors. For intimate partner violence taking place within the year before the interview, frequent quarreling was the strongest predictor. CONCLUSIONS Intimate partner violence is prevalent in China, with strong associations with male patriarchal values and conflict resolutions. Efforts to reduce intimate partner violence should be given high priority in health care settings where women can be reached.

Coercive sex in rural Uganda: prevalence and associated risk factors.

Despite growing recognition of the problem, relatively little is known about the issue of coercive sex in developing countries. This study presents findings from a community-based survey of 4279 reproductive-aged women in current partnerships in the Rakai District of Uganda carried out in 1998-99. One in four women in our study report having experienced coercive sex with their current male partner, with most women reporting its occasional occurrence. In a regression analysis of risk factors for coercive sex, conventional socio-demographic characteristics emerged as largely unpredictive of the risk of coercive sex. Behavioral risk factors-most notably, younger age of women at first intercourse and alcohol consumption before sex by the male partner-were strongly and positively related to the risk of coercive sex. Coercive sex was also strongly related to perceptions of the male partners HIV risk, with women who perceived their partner to be at highest risk experiencing almost three times the risk of coercive sex relative to low risk partnerships. Supplemental analysis of 1-year longitudinal data provides additional support for the hypothesis that coercive sex may frequently be a consequence of womens perceptions of increased HIV risk for their male partner. The findings of this study are discussed in terms of the need for sexual violence prevention programs more generally in settings such as Uganda, and in terms of the possible importance of incorporating issues of sexual and physical violence within current HIV prevention programs.

The influence of quality of care upon contraceptive use in rural Bangladesh.

Efforts to develop quantitative indicators of quality of care for family planning services, and to evaluate its role in contraceptive behavior, remain at an early stage. The present study, based upon an analysis of prospective data from a sample of 7,800 reproductive-aged rural Bangladeshi women, provides empirical evidence on the importance of quality of care for contraceptive practice. The results demonstrate that the perceptions of women regarding the quality of field-worker care were significantly related to the probability of subsequent adoption of a family planning method. Women who were not using a method and who scored high on an index of perceived quality of care were 27 percent more likely to adopt a method subsequently, compared with women with a low score. Effects were even more pronounced for contraceptive continuation; high quality of care was associated with a 72 percent greater likelihood of continued use of any method of contraception.

Maternal mortality in Matlab Bangladesh: 1976-85.

This paper reports findings from a study of maternal mortality in Matlab, Bangladesh during the 1976-85 period. The study employed a multiple-step procedure to identify maternity-related deaths to all reproductive-aged women within the study area during this period. A total of 387 maternal deaths were identified, resulting in an overall maternal mortality ratio of 5.5 per 1,000 live births. The introduction of a family planning program in half of the Matlab study area led to a moderate but significant reduction in maternal mortality rates, relative to the comparison area. This appears to have been primarily due to a reduction in the overall number of pregnancies in the treatment area, since among women who became pregnant, mortality risks remained high. The results of this study underscore the need for a broad-based service strategy that includes but is not limited solely to family planning, in order to achieve significant reductions in maternal mortality levels in settings such as rural Bangladesh.

Effects of Domestic Violence on Perinatal and Early-Childhood Mortality: Evidence From North India

OBJECTIVE We examined the effect of physical violence during pregnancy on perinatal and early-childhood mortality. METHODS We estimated the prevalence of domestic violence during pregnancy among a population-based sample of 2199 women in Uttar Pradesh, India. We used a survival regression model to examine the risks for perinatal, neonatal, postneonatal, and early-childhood (aged 1-3 years) mortality by mothers exposure to domestic violence, after we controlled for other sociodemographic and maternal health behavior risk factors. RESULTS Eighteen percent of the women in our study experienced domestic violence during their last pregnancy. After we adjusted for other risk factors, births among mothers who had experienced domestic violence had risks for perinatal and neonatal mortality that were 2.59 (95% confidence interval [CI]=1.35, 4.95) and 2.37 (95% CI=1.21, 4.62) times higher, respectively, than births among mothers who had not experienced violence. We found no significant associations between domestic violence and either postneonatal or early-childhood mortality. CONCLUSIONS Domestic violence is a significant risk factor for perinatal and neonatal mortality.

Birth Intervals and Childhood Mortality in Rural Bangladesh

This study investigates the relationship between birth intervals and childhood mortality, using longitudinal data from rural Bangladesh known to be of exceptional accuracy and completeness. Results demonstrate significant but very distinctive effects of the previous and subsequent birth intervals on mortality, with the former concentrated in the neonatal period and the latter during early childhood. The impact of short birth intervals on mortality, however, is substantially less than that found in many previous studies of this issue, particularly for the previous birth interval. The findings are discussed in terms of the potential for family planning programs to contribute to improved child survival in settings such as Bangladesh.

Maternal health and care-seeking behavior in Bangladesh: Findings from a national survey

CONTEXT Although the reduction of maternal mortality levels is a key Millennium Development Goal, community-based evidence on obstetric complications and maternal care-seeking behavior remains limited in low-resource countries. METHODS This study presents an overview of key findings from the 2001 Bangladesh Maternal Health Services and Maternal Mortality Survey of ever-married women aged 13-49. The survey collected data on the prevalence of obstetric complications, womens knowledge of life-threatening complications, treatment-seeking behavior and reasons for delay in seeking medical care. RESULTS Bangladeshi women report low but increasing use of antenatal care, as well as low rates of delivery in a health facility or with the assistance of a skilled provider. Although almost half of women reported having one or more complications during pregnancy that they perceived as life threatening, only one in three sought treatment from a qualified provider. More than three-fourths of women with the time-sensitive complications of convulsions or excessive bleeding either failed to seek any treatment or sought treatment from an unqualified provider. The principal reason cited for failing to seek care for life-threatening complications was concern over medical costs, and pronounced socioeconomic disparities were found for maternal care-seeking behavior in both urban and rural Bangladesh. CONCLUSIONS Despite these gaps in access to skilled delivery and effective emergency obstetric care, some progress has been made in reducing maternal mortality levels. Improved obstetric care and declining levels of fertility and unwanted pregnancy may have played critical roles in addressing the maternal health care needs of Bangladeshi women.

Do current measurement approaches underestimate levels of unwanted childbearing? Evidence from rural India

The validity of estimates of unintended childbearing has often been questioned, especially given their almost exclusive reliance on responses to survey questions that ask women to recall their intentions about past pregnancies. An opportunity to compare prospective and retrospective descriptions of intendedness was provided by a follow-up survey in four Indian states in 2002–2003 of rural woman originally interviewed in the 1998–99 National Family Health Survey-2. The results demonstrate a pronounced tendency for births prospectively classified as unwanted to be retrospectively described as having been wanted or mistimed. The main reason seems to be either that mothers adapt to the reality of a new birth or are reluctant to describe an existing child as having initially been unwanted. Our findings suggest that retrospective accounts of the wantedness of a birth, such as those obtained by current Demographic and Health Surveys, may lead to significant underestimates of true levels of unwanted childbearing.