Chapter 1

The chapter introduces the social and health problem of intimate partner violence (hereafter referred to as IPV[1]), highlights gaps in the research on IPV around the time of pregnancy in Bangladesh, and outlines the aims of the current research. It also provides a layout of the dissertation.

1.1 Contextualizing the problem

Pregnancy has been described as a life-changing event for women, introducing a range of new trials and tribulations. On the one hand, pregnancy is often a time of happiness and expectancy characterized by maternal optimism, emotional uplifts and growing social support (DiPietro, Hilton, Hawkins, Costigan, & Pressman, 2002; Ogbonnaya, Kupper, Martin, Macy, & Bledsoe-Mansori, 2013). Culturally, pregnancy is often viewed as a time of happiness and expectancy in women’s lives, with the welcoming of the next generation and growing anticipation of the joys a new child will bring to the family. However, pregnancy can also be a stressful and anxiety-provoking life event (Bondas & Eriksson, 2001) since it is a major life transition (Bost, Cox, Burchinal, & Payne, 2002) and, for some women, poses a maturational crisis they are ill-prepared for (Bondas & Eriksson, 2001). Regrettably, pregnancy can also introduce an increased risk for experiencing intimate partner violence (IPV) for millions of women of reproductive age worldwide (Chang et al., 2005; Devries et al., 2010; Garcia-Moreno & Watts, 2011; James, Brody, & Hamilton, 2013; Kendall-Tackett, 2007). IPV is the most frequent form of violence against women and includes acts of physical, sexual and psychological coercion as well as controlling behaviours by a current or former intimate partner or husband (World Health Organization (WHO) & Pan American Health Organization (PAHO), 2012).

Home is often considered as a haven for women and children, where there is physical and psychological safety, trust and care (Fisher et al., 2013). However, partner violence is a complete contravention of this and makes what should be a place of safety, an environment characterized by threat (Dobash & Dobash, 1979). It occurs among all socioeconomic, religious, cultural backgrounds, heterosexual or same-sex couples, and perpetration can be bidirectional (Campbell et al., 2002; Ellsberg, 2006; Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002; Watts & Zimmerman, 2002). While estimates vary widely, population-based studies indicate that anywhere from 15–71% of women experience IPV worldwide (Ellsberg & Heise, 2005; Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006). A recent meta-analysis that included studies from the US as well as other developed and developing countries, established the prevalence of IPV during pregnancy to be between 4.8% and 63.4% (James, Brody, & Hamilton, 2013). Although, there is no conclusive evidence that women who are pregnant are at greater risk for IPV victimisation (Campbell, Garcia-Moreno, & Sharps, 2004; Devries et al., 2010; Macy, Martin, Kupper, Casanueva, & Guo, 2007; Martin, Mackie, Kupper, Buescher, & Moracco, 2001; Saltzman, Johnson, Gilbert, & Goodwin, 2003), evidence suggests that a significant number of women are exposed to IPV at this vulnerable period, which in turn, jeopardise their lives (Devries et al., 2010; James, Brody, & Hamilton, 2013; Taillieu & Brownridge, 2010).

IPV has a multidimensional radiating impact on women’s lives; it affects women’s physical, sexual, mental and reproductive health (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006; Plichta, 2004; Trabold, Waldrop, Nochajski, & Cerulli, 2013), and well-being (Krantz, 2002; Riger, Raja, & Camacho, 2002). IPV damages women’s capacities to pursue education and work (McCloskey et al., 2007; Nurius et al., 2003) resulting in increased risk of poverty, divorce and unemployment (Byrne, Resnick, Kilpatrick, Best, & Saunders, 1999; Salomon, Bassuk, & Browne, 1999). It causes more deaths and incapacity among women of reproductive age than cancer, traffic accidents and malaria combined (Gomez-Beloz, Williams, Sanchez, & Lam, 2009). Along with physical and emotional impacts, victims of IPV have also lost a total of approximately 8 million days of paid work yearly, equivalent to 32,000 full-time jobs due to IPV in the US (National Center for Injury Prevention and Control, 2003). Each year IPV costs the US economy $12.6 billion (WHO, 2004) and the Australian economy $13.6 billion (Australian Bureau of Statistics (ABS), 2013). Homicide is the most extreme consequence of IPV (WHO, 2011). IPV during pregnancy poses a grave risk to two lives – mothers and unborn babies.

IPV during pregnancy is a crucial public health risk and has implications for the health and welfare of the mother, the developing fetus and the newborn during gestation, birth and postpartum (Cha & Masho, 2014; de Jager, Skouteris, Broadbent, Amir, & Mellor, 2013; Islam, Baird, Mazerolle, & Broidy, 2017; Kendall-Tackett, 2007; Lau & Chan, 2007; Leneghan, Gillen, & Sinclair, 2012; Liou, Wang, & Cheng, 2014; Trabold, Waldrop, Nochajski, & Cerulli, 2013). Established direct health consequences of IPV during pregnancy include increased risk of unwanted pregnancy, preterm birth, miscarriage (Shah & Shah, 2010), low birth weight (Bonomi et al., 2006; Dillon, Hussain, Loxton, & Rahman, 2013), emotional distress, depression, anxiety, posttraumatic stress disorder and low self-esteem (Howard, Oram, Galley, Trevillion, & Feder, 2013; Yoshihama, Horrocks, & Kamano, 2009). Indirect health consequences include substance abuse (Datner, Wiebe, Brensinger, & Nelson, 2007; Lipsky, Holt, Easterling, & Critchlow, 2005; Sarkar, 2008), constrained access to antenatal care (Bailey & Daugherty, 2007; Cha & Masho, 2014), insufficient weight gain during pregnancy (McFarlane, Campbell, Sharps, & Watson, 2002; Shadigian & Bauer, 2004), disturbances in maternal-child bonding (Janssen et al., 2003; Sharps, Laughon, & Giangrande, 2007; Trabold, Waldrop, Nochajski, & Cerulli, 2013) and early cessation of exclusive breastfeeding (Islam, Baird, Mazerolle, & Broidy, 2017; Taveras et al., 2003). IPV-related homicide is the leading cause of maternal mortality (Chang, Berg, Saltzman, & Herndon, 2005; Cheng & Horon, 2010), accounting for 13% to 24% of all deaths among pregnant women (Plichta, 2004). Once considered a family matter, IPV is now increasingly recognized as a social problem, a critical global health concern (WHO & PAHO, 2012) and a fundamental human rights issue (Amnesty International, 2004; WHO, 2006) due to its deleterious consequences on women.

Because IPV generally occurs in private, many instances of IPV are rarely reported (Flury, Nyberg, & Riecher-Rössler, 2010; Keeling & Mason, 2011), and victims often fear that reporting will increase their risk of potential harm. Additionally, women consider the trade-offs between suffering from IPV and tarnishing their social reputation, which contributes to the low reporting of IPV (Khatun & Rahman, 2012). However, in the past two decades, there has been a dramatic increase in the scope and breadth of research interest in IPV across various disciplines, including criminology, psychology, public health, social work and sociology (Loue, 2001). It is a problem beyond criminal justice, impacting health, legal, economic, education, development, and human rights as well (Malyadri, 2013). After decades of global feminist activism, international institutions now recognize the significance of violence against women (Cook & Kaya, 2010). In 1993, the United Nations began a major initiative targeting violence against women (Johnson, Ollus, & Nevala, 2007), and the WHO now defines violence against women as a serious threat to women’s health, and has been running a major research initiative (Ellsberg & Heise, 2005) in an attempt to address the devastating effects of IPV worldwide.

Although our understanding regarding the risks of IPV during pregnancy is progressing, notable gaps remain. Currently, most of the research on the prevalence, correlates and consequences of IPV during pregnancy and postpartum period have been thoroughly examined in high-income countries (Annan, 2008; Brown, McDonald, & Krastev, 2008), although IPV during pregnancy is commonly occurred in low-and-middle-income countries (27.7%–32%) compared with high-income countries (12%–13.3%) (Devries et al., 2010; James, Brody, & Hamilton, 2013). Limited research has explored these issues in low-income countries including Bangladesh (Fisher et al., 2012; Nasir & Hyder, 2003; Taillieu & Brownridge, 2010). According to Taillieu and Brownridge (2010), IPV during pregnancy in low-income countries is a relatively new area of investigation, and thus, less is known about factors contributing to violence during pregnancy and following childbirth in developing nations. The majority of research has focussed primarily on physical and/or sexual IPV (Howard, Oram, Galley, Trevillion, & Feder, 2013; Scribano, Stevens, & Kaizar, 2013; WHO, 2011). Little is known about the prevalence and correlates of sexual and psychological IPV during pregnancy, although sexual and psychological IPV around the time of pregnancy are proven to have detrimental consequences for women and their children (Chan et al., 2011; Taillieu & Brownridge, 2010; WHO, 2011). Given the potentially profound effects that IPV during pregnancy can have on the physical and mental wellbeing of women and their children, we also need to understand the impact of IPV on pregnant women’s health seeking behaviour in developing countries (Koski, Stephenson, & Koenig, 2011). Comprehensive research focusing on IPV and women’s mental health is scarce (Hegarty, 2011), and it is unclear how the experience of IPV before, during and after pregnancy affects women’s psychological health during the postpartum period (Reichenheim, Moraes, Lopes, & Lobato, 2014). Additionally, IPV during pregnancy may compromise women’s exclusive breastfeeding (EBF, only breast milk until 6 months of age, and thereafter its complementation with safe foods until the child reaches ≥ 2 years) efforts, which can further compromise the health of their newborn. Few studies have examined the influence of IPV on the continuation of EBF (Kendall-Tackett, 2007; Lau & Chan, 2007; Moraes, Oliveira, Reichenheim, & Azevedo, 2011), and therefore the association is poorly understood in the literature (Henderson, Evans, Straton, Priest, & Hagan, 2003).

In summary, there are significant gaps in the knowledge and understanding of IPV around the time of pregnancy, and the influence of different forms of IPV before, during and after pregnancy on maternal health service utilization, maternal mental health, and breastfeeding practices especially in low- and middle-income countries including Bangladesh. To improve the health of expectant mothers and their infants, it is important to investigate the potential correlates for, the co-occurring nature and patterns and the consequences of IPV around the time of pregnancy (Brownridge et al., 2011).

1.2 Setting the context: Bangladesh

1.2.1 Overview of Bangladesh

The people’s republic of Bangladesh is a developing country located in South Asia. With over 160 million people in a 147,570 km² land mass, it is world’s eighth-most populous country, and one of the most densely-populated (~1,077/ km²) nations in the world (GOB, 2016). The per-capita income is estimated at US$1,466 for the fiscal year 2016 compared to the world average of US$14,301 (GOB, 2016). Eighty-three percent of the population lives on less than US$2 per day, 25% on less than US$1 per day, and 31.5% of people live below the international poverty line of a per capita income of US$ 1.25 per day (United Nations Development Programme (UNDP), 2015). Adult literacy rate (15+ years) for both sexes is 63.6% and male-female ratio is 100.3:100 (GOB, 2016). In 2015, among 188 countries, Bangladesh ranked 142^nd position in the Human Development Index, and 111^th position in the Gender Inequality Index (UNDP, 2015). The low ranking in the gender inequality index implies that there is significant inequality in income and education between males and females in the society of Bangladesh.

1.2.2 Prevalence of IPV in Bangladesh

Bangladesh has the highest prevalence of sexual and physical IPV among South Asian countries, and it ranks second in the World Bank top 15 countries with the highest global prevalence of physical IPV (Solotaroff & Pande, 2014). The WHO multi-country study states that the lifetime prevalence of physical IPV in Bangladesh ranges from 40%–42%, the sexual IPV ranges from 37–50% and either physical or sexual IPV or both ranges from 53–62% (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006). The Bangladesh Demographic and Health Survey (BDHS)-2007 reports 48% of ever-married women have experienced physical IPV (NIPORT et al., 2009). Other studies from Bangladesh have reported the past year or current prevalence of physical IPV to be between 16–52% (Dalal, Rahman, & Jansson, 2009; Kabir, Nasreen, & Edhborg, 2014; Sambisa et al., 2010), sexual IPV between 11–65% (Bangladesh Bureau of Statistics (BBS), 2013; Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006; Kabir, Nasreen, & Edhborg, 2014; Naved, 2013), and psychological IPV between 24–84% (Dalal, Rahman, & Jansson, 2009; Kabir, Nasreen, & Edhborg, 2014).

A number of Bangladeshi studies have documented the prevalence of IPV in general, however, a few of them also inquired about its presence during pregnancy. These studies indicated a range of 10–22% of the ever-pregnant women experienced physical IPV (Åsling‐Monemi, Tabassum Naved, & Persson, 2008; Bates, Schuler, Islam, & Islam, 2004; Kabir, Nasreen, & Edhborg, 2014; Naved & Persson, 2008), 10–21% experienced sexual IPV (Hadi, 2000; Kamal, 2013) and 38% experienced psychological IPV during pregnancy (Bhuiya, Sharmin, & Hanifi, 2003). Regardless of the varied prevalence rates across studies, what is abundantly clear is that violence against women in Bangladesh is widespread so much so that the UNICEF defines IPV in Bangladesh as one of the most blatant manifestations of gender asymmetry (United Nations Children’s Fund (UNICEF), 2011).

1.2.3 Rationale for IPV study in Bangladesh

Maternal and child health has traditionally been considered an important indicator of the health progress and the overall social and economic well-being of a country (Abedin, Islam, & Hossain, 2008). Although considerable progress has been made in reducing maternal mortality globally, Bangladesh remains a leader in maternal mortality, with a ratio of 170 per 100,000 live births in 2013 (WHO, 2014a). It is well recognised that low use of prenatal care (Jasinski, 2004), limited postnatal care (Chakraborty, Islam, Chowdhury, Bari, & Akhter, 2003; Chaudhury, 2008; Kidney et al., 2009), and low birth assistance and attendance by a medically trained professional (Choudhury, Hanifi, Rasheed, & Bhuiya, 2000; Ronsmans et al., 2009) contributes to high maternal and child mortality. Research has begun to investigate the influence of other psychosocial risk factors on maternal and child health.

In South Asian countries including Bangladesh, family planning, major infectious diseases and malnutrition have been on the top of the public health priorities (Hosain, Chatterjee, Ara, & Islam, 2007). IPV has not been acknowledged as a significant public health concern in South Asian nations, and this is especially true in Bangladesh, and thus, it has never received considerable attention at the policy level or in the planning of health frameworks and research (Salam, Alim, & Noguchi, 2006). A study conducted by Afsana, Rashid, Thurston, & BRAC (2005) reviewed existing health policies and plans, interviewed policy makers, service providers and women, and identified some of the challenges and gaps in addressing violence against women in the health policy of Bangladesh. These include (1) absence of government’s concrete policies to address domestic violence and associated health issues; (2) lack of understanding or sensitivity to the issue of IPV and how it affects women’s health; (3) insufficient and weak laws in tackling IPV; (4) inadequate safety and security of victims and individuals working with the abused women; (5) lack of shelter homes; (6) inadequate support for counselling; and (7) lack of adequate training and awareness of health care providers, police, lawyers and other relevant service providers. Without a clear knowledge and understanding of IPV during pregnancy, health care providers, social workers and other service providers are underprepared for the challenges of treating IPV victims.

Despite the increase in the prevalence rate of IPV in Bangladesh, at present, there is little information on IPV during pregnancy and following childbirth. Almost all the research so far has been conducted in the U.S and other developed countries that are not representative of or generalizable to women of Bangladesh. A growing number of studies have been undertaken in Bangladesh to explore significant correlates and consequences of IPV victimization, however, most studies have only considered women of reproductive age in general, and have not investigated the experience of IPV during pregnancy. Only a single study conducted by Naved and Persson (2008) focuses on pregnant women’s experiences on physical IPV only. Except for the single study by Rahman et al. (2012) which ascertained the effect of physical and sexual IPV (did not examine psychological IPV ) on maternal health services utilization using the BDHS-2007 data, no other studies in Bangladesh have specifically examined the impact of IPV during pregnancy on the receipt of prenatal care. At present, there are very few studies in Bangladesh that have examined the prevalence of psychological or sexual IPV during pregnancy nor are there studies that have examined physical, sexual or psychological IPV during the postpartum period. Currently, there are no studies that have focused on maternal exposure to IPV during and after pregnancy, which is independently associated with postpartum depression. Furthermore, no studies in Bangladesh have investigated the effect of IPV during pregnancy on mother’s exclusive breastfeeding efforts.

Addressing the abovementioned gaps, the present study examines IPV victimization during pregnancy. It also explores the influence of IPV around the time of pregnancy on the timing of entry into prenatal care, experiencing postpartum depression and exclusive breastfeeding among women in Bangladesh.

1.3 Purpose of the study

According to Taillieu and Brownridge (2010) research on IPV during pregnancy lacks a guiding theoretical framework. There is also a global gap in the understanding of the relationship between pregnancy, childbirth and IPV. The study aims to fill some of the important gaps in the empirical evidence to help explain the prevalence, correlates and consequences of different forms of IPV before, during and after pregnancy. Currently, our understanding of the influence of IPV during pregnancy on exclusive breastfeeding practices is very limited and therefore, it is envisaged that the findings from this study will help to permeate the theoretical gap in this area. Policy makers should have a comprehensive understanding of how gender inequity increases the risk of IPV and affects the health of women and children. The research findings from this study will have implications in formulating policy and programs for IPV prevention strategies as well as maternal and child health improvement in Bangladesh and in other similar settings. Furthermore, findings from the research will also inform culturally specific educational programs on IPV for healthcare professionals, social workers, and for the women themselves in Bangladesh and other developing countries.

Pregnancy is one of the few times when almost all women need to visit health care settings on several occasions, thereby providing an opportunity for health professionals to identify IPV by routine enquiry, provide health-related services, and facilitate access to non-health support services (Jeanjot, Barlow, & Rozenberg, 2008; Martin & Garcia, 2011). Currently, Bangladesh does not have a screening protocol. The findings from this study will provide the basis for preparing nationally appropriate guidelines that would aid in the identification of women experiencing or at risk for IPV, and facilitate appropriate intervention including supportive referral and proper counseling by trained health care providers and social workers.

1.4 Research Questions

The research aims to answer two questions:

RQ1 How do pregnancy and the postpartum period influence the prevalence of IPV?

RQ2 Does IPV influence delayed entry into prenatal care, postpartum depression and mother’s exclusive breastfeeding?

1.5 Aims of the study

To address the first research question, this study broadly examines IPV victimisation during pregnancy among women in Bangladesh with specific aims to:

Aim-1: Examine IPV victimisation for pregnant women in Bangladesh.

To detail the impacts of IPV on the health of mothers and babies, the study addresses the following specific aims:

Aim-2: Explore the health consequences of IPV victimisation for pregnant women in Bangladesh.

1.6 Thesis framework

The thesis is structured in five portions including introduction, literature review, research process, research contribution and conclusion and consists of eight chapters (as shown in Figure 1.1).

Figure 1.1: Thesis Framework

Introduction

Chapter 1 contextualises the problem of IPV during pregnancy and postpartum period. It explores the Bangladeshi context including the prevalence of IPV. This chapter also provides the purpose, objectives and research questions of the study.

Literature review

Chapter 2 presents a review of the available literature on IPV and pregnancy-prevalence and changing pattern of IPV both during and after pregnancy and potential correlates of IPV during pregnancy that has relevance with the cultural context of Bangladesh. It also elaborately illustrates direct and indirect consequences of IPV before, during and after pregnancy.

Chapter 3 depicts the contextual reasons for IPV victimization during pregnancy followed by the theoretical perspectives of IPV. Among theories, feminist theory, social learning theory and evolutionary psychological theory are elaborately explained. At the end of this chapter, a conceptual framework has been developed based on the theories and past literature of IPV.

Research process

Chapter 4 focuses the methodology of the study. This part consists of study design, data collection sites, sample of the study, detailed procedure in undertaking the study and research instruments. Finally, ethical considerations are highlighted in this chapter.

Research contribution

During the PhD candidature, the candidate made a considerable contribution to five published and unpublished peer-reviewed journal articles (two has already been published and three are under review), which confirms the originality of this research (presented in Chapter 5, 6 and 7, as shown in Table 1.1). Paper I addresses research aim 1.1 and 1.2. Paper II, III, IV and V address aim 1.3, 2.1, 2.2 and 2.3 respectively. The articles are listed as follows:

Table 1.1: Published and unpublished articles from this thesis

Analytical results and significance of the findings are discussed in chapter 5–7.

Chapter 5 presents the analytical results of aim 1 (RQ1). Prevalence, potential risk factors of IPV during pregnancy, and changing pattern of IPV throughout the pregnancy are identified and described in this chapter.

Chapter 6 discusses the analytical results of aim 2 (RQ2). The influence of IPV on the timing of entry into prenatal care, postpartum depression and mother’s exclusive breastfeeding are explored in this chapter.

Chapter 7 discusses the significance of the findings outlined in chapter 5 and chapter 6 in light of past studies and theoretical frameworks.

Conclusion

To conclude, chapter 8 presents the summary of the core research findings extracted from the study. Having outlined the limitations of the research, the outlook for future research directions is also stated in this chapter.

Chapter 2

The prevalence of IPV directed at pregnant women in both developed and developing countries remains elusive and varies widely from study to study depending on how IPV has been assessed. Variation in IPV prevalence estimates may be due to actual differences in the prevalence of violent acts within different study populations, as well as differences in methodologies, definitions and cultural aspects among studies that make it difficult to compare the results (Jasinski, 2004; Jeanjot, Barlow, & Rozenberg, 2008; Taillieu & Brownridge, 2010). With varied prevalence rates of IPV, a number of risk factors relevant to understanding the risk of IPV during pregnancy are also available in the literature. In the first part of this chapter, the prevalence of IPV during and after pregnancy, and the patterns of IPV experienced by pregnant women are discussed. Further, the factors that put women at risk for experiencing IPV during pregnancy and the negative consequences of IPV during pregnancy are demonstrated in the later part of this chapter.

2.1 Prevalence of IPV during pregnancy

Gazmararian et al.’s (1996) review, synthesizing the results of 13 studies from the USA and other developed countries reveals that the prevalence of IPV against pregnant women ranges from 0.9% to 20.6%, with most studies reporting estimates between 3.9% and 8.3% (Gazmararian et al., 1996; Martin, Mackie, Kupper, Buescher, & Moracco, 2001; Saltzman, Johnson, Gilbert, & Goodwin, 2003). Another review of six studies from developing countries (including India, China, Pakistan and Ethiopia) reports that the prevalence of IPV during pregnancy is between 4% and 29% (Nasir & Hyder, 2003). A review of 19 studies from some African countries has documented that 8 to 57.1% pregnant women experience IPV during pregnancy (Shamu, Abrahams, Temmerman, Musekiwa, & Zarowsky, 2011). Another systematic review consolidating findings from both developed and developing nations has documented the prevalence as 0.9-30% physical violence, 1-3.9% sexual violence, and 1.5-36% psychological violence during pregnancy (Taillieu & Brownridge, 2010). A recently published meta-analysis synthesizing the results of 92 studies from both developed and developing countries reports that the prevalence of IPV against pregnant women varies between 4.8% in China and 63.4% in Brazil (James, Brody, & Hamilton, 2013). This review also reveals that the prevalence of psychological IPV to be 28.4%, physical IPV to be 13.8% and sexual IPV during pregnancy to be 8%. Notably, the prevalence of IPV against pregnant women appears to be higher in African and Latin American countries compared to the Asian and European countries (Devries et al., 2010).

The literature contains mixed results concerning whether pregnancy is a vulnerable period for IPV and whether IPV escalates in severity during pregnancy. A number of factors are responsible for these discrepancies. First, IPV (e.g. physical, sexual, and/or psychological) has been defined differently from study to study (McMahon & Armstrong, 2012). IPV measurements that include multiple items and consider a number of different types of violence tend to result in the highest prevalence rates (Farid, Saleem, Karim, & Hatcher, 2008; Perales et al., 2009). Furthermore, IPV has been assessed with a range of instruments including the Conflict Tactics Scales, the Danger Assessment Scale, the Abuse Assessment Scale and the Index of Spouse Abuse, among other instruments. Second, the pregnancy period has been defined variously, up to one-year pre- or post-delivery (McMahon & Armstrong, 2012). Third, prevalence rates vary whether national or community samples are used, with community samples reporting more violence than national samples (Bailey & Daugherty, 2007; James, Brody, & Hamilton, 2013; Jasinski, 2004). Fourth, prevalence rates also vary whether population-based samples or hospital or clinic-based samples are used. Notably, population-based studies have found lower rates of IPV than hospital-based samples (Guo, Wu, Qu, & Yan, 2004b; James, Brody, & Hamilton, 2013; Janssen et al., 2003; Yost, Bloom, McIntire, & Leveno, 2005). Fifth, the prevalence is higher in low-income countries in comparison to high-income countries and within countries, it is higher in rural areas than in urban areas (Fanslow, Silva, Robinson, & Whitehead, 2008; Naved & Persson, 2008; Peek-Asa et al., 2011; Valladares, Pena, Persson, & Hogberg, 2005). Sixth, prevalence rates vary depending on the timing of inquiry (e.g. single point early in pregnancy vs. multiple points during pregnancy). Finally, the mode of inquiry (Self-administered questionnaire vs face-to-face interview) also plays an important role in estimates of prevalence rate. Higher prevalence rates have been associated with in-person interviews than self-administered questionnaire (Gazmararian et al., 1996).

Although the prevalence of IPV during pregnancy vary, it is clear that a significant number of women experience IPV during pregnancy. For this thesis, a comprehensive search of the current studies has been undertaken on the prevalence of IPV before, during and after pregnancy. The results are summarized in Table 2.1.

2.2 Prevalence of IPV during postpartum period

The postpartum period begins immediately after the birth of the baby and extends up to six weeks (WHO, 2014b) to six months after birth (Brown, Posner, & Stewart, 1999). Since most deaths occur during the postpartum period, WHO describes this period as the most critical and yet, the most neglected phase in the lives of mothers and babies (WHO, 2014b).

A number of studies have demonstrated that the risk of IPV associated with pregnancy is not only limited to the time between conception and birth, but also the period of one year before conception until one year after childbirth (Charles & Perreira, 2007; Jasinski, 2004; Martin et al., 2004; Saltzman, Johnson, Gilbert, & Goodwin, 2003; Taillieu & Brownridge, 2010). An increasing number of studies have shown that the postpartum period is also a time of increased risk for IPV victimisation (Ezechi et al., 2004; Hedin, 2000; Macy, Martin, Kupper, Casanueva, & Guo, 2007; Martin et al., 2004; Silva, Ludermir, de Araujo, & Valongueiro, 2011; Woolhouse, Gartland, Hegarty, Donath, & Brown, 2012). Previous studies have reported that IPV during the postpartum period ranges from 2–25% (Charles & Perreira, 2007; Gartland, Hemphill, Hegarty, & Brown, 2011; Hellmuth, Gordon, Stuart, & Moore, 2013; Saito, Creedy, Cooke, & Chaboyer, 2012; Silva, Valongueiro, Araújo, & Ludermir, 2015).

One longitudinal study has reported that the rates of psychological and sexual IPV are the highest during the first month after the birth of the infant (Macy, Martin, Kupper, Casanueva, & Guo, 2007). One study reports that the prevalence of physical IPV in the postpartum period is around eight times higher in women who have also experienced IPV during pregnancy as compared to those who have not (Moraes et al., 2011). Another study has revealed that physical IPV among young mothers is as high as 21.3% at 3 months postpartum, and 78% of these women have reported no IPV before pregnancy (Harrykissoon, Rickert, & Wiemann, 2002). In the same study, 75% of mothers experienced IPV during their pregnancies also reported IPV within 24 months following birth.

Table 2.1: Worldwide prevalence of IPV during pregnancy and postpartum period from previous research