Psychosexual health
DOI: 10.1111/j.1471-0528.2012.03401.x www.bjog.org
Abuse from in-laws and associations with attempts to control reproductive decisions among rural women in Coˆte d’Ivoire: a cross-sectional study J Gupta,a K Falb,b D Kpebo,c J Annand a
Division of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA b Department of Society, Human Development and Health, Harvard School of Public Health, Boston, MA, USA c Innovations for Poverty Action, Abidjan, Coˆte d’Ivoire d International Rescue Committee, New York, NY, USA Correspondence: J Gupta, Yale School of Public Health and Center for Interdisciplinary Research on AIDS, College Street, Suite 400, New Haven, CT 06510, USA. Email
[email protected] Accepted 24 April 2012. Published Online 7 June 2012.
Objective To document the lifetime prevalence of abuse from
Main outcome measures Lifetime, in-law-perpetrated
in-laws (both nonphysical maltreatment and physical violence), the forms of in-law abuse and reproductive control, and the relationship between experiences of in-law abuse and reproductive control among partnered women in rural Coˆte d’Ivoire.
reproductive control.
Design Cross-sectional study using baseline data (October 2010) from a randomised controlled trial examining socio-economic interventions on reduction of violence against Ivorian women. Setting Rural Coˆte d’Ivoire. Population A total of 981 Ivorian women aged 18 years and older
who reported having a male partner and a current source of stable income. Methods Bivariate and multivariable logistic regression.
Results More than one in four (27.0%) women reported experiencing lifetime in-law abuse. In adjusted logistic regression analysis, in-law abuse was significantly associated with in-lawperpetrated reproductive control (adjusted odds ratio 6.9; 95% confidence interval 3.9–12.2; P < 0.0001). Religion and having fewer pregnancies were also associated with reporting in-lawperpetrated reproductive control. Conclusions Increased efforts are needed to involve in-laws in
programmes that seek to reduce gender-based violence against women and improve women’s reproductive health. Keywords Gender-based violence, in-laws, reproductive control,
West Africa.
Please cite this paper as: Gupta J, Falb K, Kpebo D, Annan J. Abuse from in-laws and associations with attempts to control reproductive decisions among rural women in Coˆte d’Ivoire: a cross-sectional study. BJOG 2012;119:1058–1066.
Introduction Intimate partner violence (IPV) against women by a male partner is a serious public health and human rights concern that has been documented to impact 10–76% of women worldwide.1,2 It has been associated with a vast range of negative reproductive health outcomes, including increased risk of sexually transmitted infections,3,4 unintended or unwanted pregnancies,2 abortion5 and poor maternal health outcomes.6 The World Health Organization and the United Nations are spearheading efforts to reduce violence against women, and improve their status,
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because reducing violence against women is essential if their health is to be improved.7–10 An important component of prevention is to understand why men perpetrate violence against women, and how we can alter this behaviour. Increasingly, programmatic and research attention is being devoted to understanding men’s risk factors for perpetration of IPV as well as interventions designed to change such behaviours and inequitable attitudes.11–13 Though multi-country global studies have not been conducted to date, in many developing country contexts, violence against women has been documented to be perpetrated not only by male partners but also by the family
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
Abuse from in-laws and reproductive health in Coˆte d’Ivoire
members of male partners (i.e. in-laws); with prevalence of violence from family members ranging from 5 to 26%.14–17 Similarly, a notable collection of studies has found increased likelihood of in-law-perpetrated violence when male-perpetrated IPV is present.14,16–18 Abuse, including maltreatment and violence, from the extended family members may be similar to experiences of IPV in which a woman may have restricted ability to seek health care and may experience emotional and physical abuse;17 however, maltreatment from the extended family may take other forms, typically not addressed within the IPV literature. These additional manifestations may include encouraging the husband to perpetrate IPV, domestic servitude, criticising a woman’s natal family, and complaining about dowry.16 Among the small collection of studies that have examined in-law-perpetrated abuse against women, the overwhelming majority of such work has primarily focused on populations in Asia/South Asia and the Middle East.15,17,19 Far less is known about in-law-perpetrated abuse in other developing country contexts, particularly those in West Africa. Such work is important because, like South Asian cultures, social norms in many West African societies can be characterised by cultural expectations of daughter-in-law subservience to the husband’s family, particularly where the extended family can have power over the married couple.17,20 Despite these shared cultural norms, which have been documented to be an important factor that is associated with abuse from in-laws, and the high levels of male perpetrated IPV (30–60%) observed in the few studies on this issue in West Africa,21–25 research on in-laws as perpetrators of violence against women in West Africa is lacking. In addition to the documentation of the levels and forms of in-law abuse in diverse contexts, there is also a need to understand mechanisms by which such violence can impact a woman’s reproductive health. Qualitative reports primarily from South Asia and the Middle East also suggest that, similar to IPV, maltreatment from family members may negatively impact reproductive health;17,19,26 including decisions regarding the number of children or sons, sterilisation choices,19 or discontinuation or interference with contraceptive methods,26 and one quantitative study with Jordanian women found a notable prevalence of women reporting in-law interference with reproductive decisions (e.g. 7% from mothers-in-law).26 Although anecdotal accounts from programmes working to address IPV in Coˆte d’Ivoire have expressed concern regarding abuse from women’s in-laws, the extent to which these observations apply to the West African context is currently unclear and quantitative investigation of these observations and how they relate to abuse from in-laws remain underinvestigated. Moreover, recent work in the USA indicates that reproductive coercion, which can involve explicit pressure from the
partner to become pregnant, or actual manipulation of birth control,27 may be a critical dimension through which IPV can increase the risk of negative reproductive health.28,29 To date, however, existing research on reproductive coercion has primarily been conducted within the context of partner-perpetrated IPV in the USA; little work has explicitly examined this issue in developing nations nor has any work to date quantitatively investigated the relationship between in-law-perpetrated abuse and reproductive control. In developing countries, increased understanding of in-law-perpetrated abuse, reproductive control and reproductive health is imperative for community-based programmes and health providers within clinical settings to better address unintended pregnancy, unmet family planning needs, and experiences of violence among women while explicitly incorporating the larger familial context in which women reside. Community-based data from rural regions within the Republic of Coˆte d’Ivoire, a conflict affected, West African nation where there are both high levels of IPV and troubling indicators of women’s reproductive health (e.g. only 7.3% of partnered Ivorian women use modern contraception, compared with 21.4 and 56.1% in Africa and the world, respectively;30 only 4.6% of partnered Ivorian women report use of modern contraception in rural areas;31 and almost 30% of women have unmet family planning needs),32 provided a unique opportunity to investigate the association of interest. Increased understanding is urgently needed in Coˆte d’Ivoire because it is not on target to meet the Millennium Development Goal 5 with an estimated maternal mortality ratio of 470 maternal deaths per 100 000 live births in 2008.33 In addition, Coˆte d’Ivoire ranks 146 of 157 countries in the Gender-related Development Index, which reflects staggeringly unequal gender norms,32 conceptualised as differential social expectations and behaviours of males and females in a society that can result in health or social inequalities between genders.34 The objectives of the present study were to document: (1) the lifetime prevalence of abuse from in-laws (both nonphysical maltreatment and physical violence); (2) the forms of in-law abuse and reproductive control, and (3) the relationship between experiences of in-law abuse and reproductive control among partnered women in rural Coˆte d’Ivoire.
Methods Study design The present investigation uses baseline data from an ongoing 2-year cluster randomised controlled trial (Reduction of gender-based violence against women in Cote d’Ivoire) undertaken by the Yale School of Public Health and Innovations for Poverty Action in partnership with the International
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Rescue Committee (IRC). The overarching goal of the study is to identify and evaluate sustainable interventions for the prevention and mitigation of violence against women in rural areas affected by conflict. The intervention consists of groups within villages randomised to receive either an economic intervention only (assignment to village savings and loans associations [VSLA]) to promote economic independence for women, or to VSLA plus a gender dialogue group (VSLA+). The latter intervention arm also incorporates social change strategies to support gender-equitable attitudes between men and women to reduce women’s susceptibility to violence. Gender dialogue groups specifically encourage discussion among couples regarding negotiating decision making within the household and men’s respect for women. Funded by the World Bank’s State and Peace-Building Fund (SPF), the baseline study was conducted over 2 weeks in October 2010. In consultation with the IRC (the implementers of the intervention), the research team selected 24 villages for inclusion into the study provided they met the following criteria: (1) no previous experience with any type of microfinance intervention, and (2) located in rural regions because of the intervention’s reliance on high social cohesion, which is likely to be stronger in rural settings. Before the baseline survey, IRC staff announced to the communities that VSLA groups were forming and any woman interested in participating was invited to do so. Inclusion criteria for women participants were being older than 18 years, reporting a current source of income, and no previous participation in any other microfinance activities. Both partnered and unpartnered women were invited to participate to preserve social cohesion in the community; unpartnered women were given an abbreviated questionnaire. The hour-long, paper-based survey was administered to participants by language/ethnicity-matched, locally trained, female survey enumerators in a private location. Female enumerators read each item aloud to women participants, along with corresponding answer choices. The survey was translated into ten local languages and was piloted before the study. The overall response rate for the baseline survey was 96%, yielding a total sample size of 1273 women, of whom 981 (77.1%) were partnered. All survey protocols were approved by the Human Subjects Committee at Yale University. All women completed informed consent and were informed that their decision to participate or early withdrawal from the study would not affect their relationship with IRC.
Measures Assessment of lifetime experiences with in-law-perpetrated reproductive control was conducted via adaptation of a US-based pregnancy coercion scale developed for use with adolescent girls to assess experiences of pregnancy coercion
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perpetrated by a male dating partner.28 The analyses conceputalizes in-laws as family members of the partner’s family, regardless of marital status. The following items were included: ‘Have your in-laws or member of your partners’ family ever: (1) told you not to use any birth control; (2) told your husband to prevent you from using any birth control; (3) told your husband to leave you if you did not get pregnant; (4) told your husband to have a baby with someone else if you didn’t get pregnant; (5) told your husband to hurt you physically if you did not get pregnant; (6) not allowed you to eat if you did not become pregnant; (7) insulted or humiliated you if you did not become pregnant; (8) tried to force or pressure you to become pregnant, and (9) not allow you in the house if you did not become pregnant?’ An additional item, ‘hurt you physically because you did not get pregnant,’ was removed from the scale for the current analyses because of its overlap with in-law-perpetrated abuse. A positive response to any item was defined as experiencing reproductive control. Responses were dichotomised as ‘yes’ to any item indicating reproductive control versus ‘no’ to all items indicating no reproductive control. The scale indicated high reliability (Cronbach’s a = 0.93). Lifetime experiences with in-law-perpetrated abuse was assessed through eight items that were adapted from items from existing partner violence scales that were modified for use in Coˆte d’Ivoire35 and a study on in-law abuse with low-income women in India.17 The items included: ‘Has anyone in your partner’s family ever: (1) belittled, intimidated, insulted, controlled, or threatened you; (2) hit, kicked, slapped, or hurt you otherwise physically; (3) interfered with your ability to seek medical care; (4) denied you food; (5) interfered with your ability to speak with or visit your natal family; (6) taken possession of things of value to you such as clothes, jewellery, or gifts from your partner; (7) encouraged your partner to humiliate you, call you names, or prevent you from leaving the home, and (8) encouraged your partner to hit, kick, punch, or otherwise physically hurt you?’ Any ‘yes’ response was coded as positive in a summary, binary variable. The scale demonstrated acceptable reliability (Cronbach’s a = 0.80). Other covariates, primarily demographic factors, included age, educational level, ethnicity, literacy, number of pregnancies, religion, occupation and marital status (defined as married, living with a partner, and not living with a partner) and were assessed through single-items.
Analysis Frequencies were generated for demographics, experiences with lifetime in-law-perpetrated reproductive control, and experiences with lifetime in-law-perpetrated abuse. We used chi-square analysis and Student’s t test(as appropriate) to examine bivariate relationships between covariates, reproductive control and in-law abuse (P < 0.05). We also
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
Abuse from in-laws and reproductive health in Coˆte d’Ivoire
generated frequencies for specific forms of in-law-perpetrated reproductive control. (It should be noted that ‘in-law’ refers to both family members of the husbands’ family as well as male partners’ family members where the respondent is not married.) We conducted crude logistic regression analyses to examine bivariate associations between lifetime in-law-perpetrated abuse with lifetime inlaw-perpetrated reproductive control. Multivariable logistic regression models were then constructed by including all covariates to examine adjusted analyses between lifetime in-law-perpetrated maltreatment (any and physical only) with lifetime in-law-perpetrated reproductive control. Adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were used to assess significance at P < 0.05. To account for the potential nonindependence of women within villages, generalised estimating equations were used to calculate unadjusted and adjusted odds ratios (ORs). All analyses were conducted in SAS 9.1.36
Results
(Table 1). Women who were literate and had no or fewer pregnancies were significantly more likely to report experiencing reproductive control from in-laws. As shown in Table 2, the most common forms of reproductive control were in-laws telling the husband to leave the woman if she did not get pregnant or telling the husband to have a baby with someone else if she did not get pregnant (64.5%; n = 40). The least common form of reproductive control was not being allowed to eat because the woman was not pregnant (3.2%; n = 2). Among those that reported maltreatment by in-laws, 15.9% reported reproductive control whereas only 2.8% of women not experiencing maltreatment reported reproductive control (P < 0.0001). Physical violence from in-laws was also significantly associated with reproductive control; 16.3% of women experiencing physical violence reported reproductive control compared with only 5.9% that did not report physical violence (P = 0.006). Illiteracy (P = 0.02) and not ever having a pregnancy (P = 0.005) were also associated with increased prevalence of reproductive control.
Sample demographics The mean age of respondents was 37.4 years (SD 11.3 years) and almost three-quarters (71.4%; n = 698) reported no schooling whereas only 6.4% (n = 63) reported attending secondary school or higher. Nearly all women reported employment and approximately 15.1% of women reported having a farming-related occupation. The most commonly reported religion was Christianity (43.1%; n = 423) and the most common ethnicity was Yacouba (62.2%; n = 610). The majority of women were married (83.9%; n = 823) and over three-quarters were illiterate (76.4%; n = 749). Most women reported having four or more pregnancies (73.1%; n = 717).
Prevalence of lifetime in-law-perpetrated abuse and associations with demographics Overall, 27.0% (n = 265) of women reported lifetime inlaw-perpetrated abuse (Table 1). Experiencing in-law abuse was associated with marital status such that those who were married reported the greatest prevalence of in-law abuse (28.3%) whereas those that were not living with a partner (8.9%) experienced the lowest prevalence of in-law abuse (P = 0.01). Ethnicity was also associated with experiencing in-law abuse; Dioula women experienced the highest prevalence of abuse (38.9%) while Mossi women experienced the lowest prevalence (6.3%) (P = 0.004).
Prevalence of lifetime in-law-perpetrated reproductive control and associations with demographics Approximately 6% (n = 62) of women reported experiencing lifetime in-law-perpetrated reproductive control
Lifetime in-law maltreatment and associations with lifetime in-law-perpetrated reproductive control In the unadjusted analyses, women who experienced in-law abuse were over six times more likely to report reproductive control (OR 6.5; 95% CI 3.8–11.2; P < 0.0001) (Table 3). In adjusted, multivariable logistic regression analysis, women who experienced in-law abuse had 6.9 times higher odds of reporting reproductive control after adjusting for a comprehensive set of covariates (95% CI 3.9–12.2; P < 0.0001) (Table 3). Overall, Guere women, women who were of Traditional faith, and women with a lower number of pregnancies were also more likely to report reproductive control in the adjusted models.
Discussion Over one in four (27.0%) of the women in this community-based study of rural Ivorian women reported experiencing abuse from their husband/partner’s family members at some point in their lifetime. This high lifetime prevalence is consistent with previous work focusing on abuse from in-laws in South Asia17 and indicates that this understudied form of violence against women is also likely to be relevant to the health and wellbeing of women in the West African context. Notably, women who were married or who were reported to be living with their partner were more likely to report in-law abuse than women who were not living with their partner at the time of the survey. Although previous work has examined in-law violence primarily among mar-
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Table 1. Demographic characteristics and associations with in-law abuse and in-law reproductive control among rural, partnered women in Coˆte d’Ivoire (n = 981) Exposure In-law abuse % (n) or mean (SD) Overall sample In-law abuse Yes No Age Education None Primary Secondary or higher Occupation None Farming-related Other Religion Christian Muslim Traditional Other None Marital status Living with partner Married Not living with partner Know how to read Yes No No. of pregnancies 0 1–3 ‡4 Ethnicity Yacouba Baoule Guere Senoufo Dioula Mossi Other
Outcome P-value
Missing
In-law reproductive control % (n) or mean (SD)
P-value
100 (981)
27.0 (265)
–
6.3 (62)
–
–
27.0 (265) 73.0 (716) 37.4 (11.3)
–
–
