Domestic Violence and Pregnancy in Nepal - Perceptions, Prevalence, Birth Preparedness and Perinatal Outcomes
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Distinct gender-related social norms and behaviors influence inequalities between men and women and build the foundation for gender-based violence. Violence against women is a major public health problem in all societies, and a violation of human rights. Surveys have shown that approximately one-third of all women worldwide have experienced such violence, and it is most prevalent in Southeast Asia. In Nepal, domestic violence perpetrated either by husbands or by inlaws in extended families is the most prevalent form of gender-based violence, also against pregnant women. Domestic violence in pregnancy is associated with maternal and child morbidity and mortality. In a developing country such as Nepal, where domestic violence is underreported due to various reasons, antenatal clinics provide a unique opportunity to address the needs of female survivors exposed to violence. The study on which this thesis is based aimed to explore perceptions of domestic violence within a Nepalese community, the prevalence of experiences of domestic violence among pregnant women and their preparedness for childbirth, and the perinatal outcomes of low birthweight, preterm birth, and mode of delivery for women exposed to violence. A qualitative exploratory study was conducted in Dhulikhel Municipality, involving 41 men and 76 women in 12 focus group discussions, in different gender-role and family-role groups. The interviews were recorded, transcribed verbatim, and analyzed using content analysis. The community recognized that culturally-specific violence is prevalent in Nepalese society, such as the pressure to give birth to sons, denial of food, and forcing pregnant women to do hard work during pregnancy, which could lead daughters-in-law to become vulnerable to domestic violence in extended families. They also perceived that promotion of a culture of normalization, endurance, and reconciliation above individual health caused women to tolerate and accept their situations. This illustrates the complexity and linkages of exposure to or protection from domestic violence at several societal levels. However, community members described how a shift towards increased awareness, changing attitudes and practices, and actions to address continuing violence were gaining momentum. In a quantitative, cross-sectional study, we included 2004 pregnant women between 12 weeks and 28 weeks of gestation who were attending routine antenatal care at Dhulikhel Hospital - Kathmandu University Hospital (DH-KUH) and Kathmandu Medical College. A total of 21% of the women had experienced domestic violence, 12.5% had experienced fear only, 3.6% violence only, and 4.9% both violence and fear. Fewer than 2% reported physical violence during pregnancy. Only 17.7% had ever been asked by health care personnel about violence, and of the women who reported domestic violence, only 9.5% had disclosed their experience to health care personnel. Women with a low socioeconomic status, no education, no income, or who came from a disadvantaged ethnic group were more likely to report experiences of domestic violence compared with more advantaged women. Assessments of birth preparedness and complication readiness among the 1011 participants at the antenatal clinic at DH-KUH showed that experience of domestic violence was associated with women who were not prepared for childbirth (aOR 2.3, 95% CI: 1.4-3.9). A total of 78% had identified a health facility, 65% had saved money, and 50% had identified a birth attendant. Less than half had arranged for transportation (38%) or a blood donor prior (20%) to childbirth. Women who were illiterate (aOR 9.9, 95% CI:5.7-17.1), young (aOR 3.4, 95% CI:1.6-7.2), in the most oppressed social class (aOR 3.0, 95% CI:1.2-7.6), had an illiterate husband (aOR 2.5, 95% CI:1.2–5.2), had less than four antenatal visits (aOR 2.0, 95% CI: 1.4-2.6), whose husband had low income status (aOR 1.7, 95% CI:1.1-2.9), or lived in rural settings (aOR 1.5, 95% CI: 1.2- 2.1) had increased odds of not being prepared for childbirth. During data collection, two devastating earthquakes occurred. As a consequence, we had to stop data collection for six weeks. We made a subanalysis of our data after this time point, but could not find any interactions between domestic violence, birth preparedness, and pre- or post-earthquake status. However, almost 62% of participants were not prepared for childbirth post-earthquake, compared with 38% pre-earthquake. Of the 2004 women who were initially included in the study, birth records were followed up for 1381 in a prospective cohort study. Associated factors were analyzed using logistic regression analyses. In total, 37.6% of the women delivered by caesarean section, 13.5% of the newborns had low birthweight, and 8.9% of the newborns were born preterm. Women aged 30 years or older were four times (cOR 4.35, 95% CI:2.19-8.63) more likely to have had caesarean sections. Similarly, women who delivered at Kathmandu Medical College were twice as likely to have undergone a caesarean section as women who delivered at Dhulikhel Hospital (aOR 2.07, 95% CI: 1.64-2.62). Being from rural settings and giving birth at Dhulikhel Hospital were significantly associated with giving birth to a low birthweight newborn. Having reported both violence and fear remained substantially associated with preterm birth in crude and adjusted logistic regression models (cOR 2.36 95% CI;1.15-4.83, aOR 2.41 95% CI;1.16-5.00). We did not find any significant association between exposure to domestic violence during pregnancy and risk of low birthweight and caesarean section. Social norms were perceived as shifting toward reduced acceptance of violence against pregnant women, but restrictions on women’s life options, movements, and decision-making authority were still considered impediments to pregnant women’s health. Substantial numbers of women reported experiences of domestic violence. Such women are vulnerable and require extra care from the health system. Our study also revealed that domestic violence is associated with preterm birth, which may cause infant mortality and morbidity. Survivors of domestic violence rarely disclosed their experiences of violence to health care personnel, and this finding underlines the importance of integrating a systematic assessment of domestic violence in antenatal care and helping women to be prepared for childbirth.