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Background Scientific literature has provided clear evidence of the profound impact of sexual violence on women’s health, such as somatic disorders and mental adverse outcomes. However, consequences related to obstetric complications are not yet completely clarified. This study aimed to assess the association of lifetime exposure to intimate partner sexual violence with eclampsia. Methods We considered all the seven Demographic and Health Surveys (DHS) that included data on sexual violence and on signs and symptoms suggestive of eclampsia for women of reproductive age (15-49 years). We computed unadjusted and adjusted odds ratios (OR) to evaluate the risk of suggestive eclampsia by ever subjected to sexual violence. A sensitivity analysis was conducted restricting the study population to women who had their last live birth over the 12 months before the interview. Results Self-reported experience of sexual violence ranged from 3.7% in Mali to 9.2% in India while prevalence of women reporting signs and symptoms compatible with eclampsia ranged from 14.3% in Afghanistan to 0.7% in the Philippines. Reported sexual violence was associated with a 2-fold increased odd of signs and symptoms suggestive of eclampsia in the pooled analysis. The sensitivity analysis confirmed the strength of the association between sexual violence and eclampsia in Afghanistan and in India. Conclusions Women and girls in low-and-middle-income countries are at high risk of sexual violence, which may represent a risk factor for hypertensive obstetric complication. Accurate counseling by health care providers during antenatal care consultations may represent an important opportunity to prevent adverse outcomes during pregnancy.
DHS are nationally representative random household surveys covering several indicators of population, with particular focus on maternal and child health [30]. All or ever-married women of reproductive age (15-49 years) are the target population in most DHS surveys. DHS guidelines are designed to maximize safety and disclosure, including interviewing only one woman per household, and maintaining complete privacy during the interview [31]. Questionnaire are translated into major local languages and data are collected via face-to-face interviews by trained personnel. In order to maximize the information comparability across countries, the core content for every round of DHS is standard and includes a complete birth and death history for the children of each eligible woman. Additional questions related to pregnancy complications may also be adopted by countries from the survey questionnaire on antenatal, childbirth and postnatal care. Several countries comprise a specific questionnaire module on exposure to intimate partner violence (IPV), which is measured by binary indicators of physical, sexual, and emotional violence [32]. Information about IPV is collected with no-one else in the household aware that this was done. The violence module is an abbreviated and modified version of the Conflict Tactics Scale [33], which classifies specific acts like “twisting your arm” as physical, emotional, or sexual violence. Ever having experienced any form of violence by their husband or partner and by their most recent husband or partner is respectively obtained from married/cohabiting and formerly married/cohabiting women [32]. Our analysis included only the most recent surveys in these countries presenting data on both IPV and reported life-threatening obstetric complications during birth of the last infant, thus limiting our analysis to one birth per woman. We pooled all the seven DHS national data sets into one cross-sectional data set containing 247 140 women of reproductive age. We excluded data on girls under the age of 15 and on women not interviewed for domestic violence because of reasons like not meeting eligibility criteria (n = 65 275). For our analysis we only considered the latest pregnancy that occurred within the three years prior to the survey, thus excluding 129 078 women; after excluding records with missing data on convulsions (n = 1429) and on covariates of interest (n = 406) as well as twin pregnancies [34] (n = 204), the final analysis consisted of 50 748 individuals (Figure 1). Study participants flowchart. We used women self-reported occurrence of convulsions not caused by fever as a proxy for the outcome (eclampsia) and women self-reported sexual violence by the partner as the exposure. As indicated by the World Health Organization [35], Intimate Partner Violence (IPV) refers to ongoing or past violence and abuse by an intimate partner or ex-partner – a husband, boyfriend or lover, either current or past. Women may suffer several types of violence by a male partner: physical violence, emotional/psychological abuse, controlling behaviours, and sexual violence. The index pregnancy corresponds with the closest pregnancy to the DHS interview in case of multiple pregnancies women. We explored several covariates. Maternal age was categorized into three groups, from age 15 to age 24, from age 25 to age 36, and from age 37 to age 49; place of residence was split into urban and rural settings; a wealth index based on asset-ownership and household characteristics data (categorized using the quintiles “poorest”, “poorer”, “middle”, “richer”, and “richest”) was considered as a proxy for socio-economic status [36]. As for literature [37], both maternal and partner’s educational attainment were included after classification in “no education”, “primary”, “secondary”, and “higher”. In consideration of the reported strong association with both maternal hypertensive complications and violence, access to antenatal care and institutional birth as well as self-decision for her own health care (proxy for woman empowerment) were explored [38-40]. We did not consider intendedness of pregnancy as it lies on the causal pathway. Finally, maternal employment status (“employed” and “unemployed”) and birth order categorized in “first birth” and “latter birth” [31] were investigated. We considered all these variables as potential confounders and adjusted for them when assessing the association between eclampsia and sexual violence (Figure 2) [38-42]. Directed acyclic graph for a proposed causal framework in the association between sexual violence and eclampsia. We use counts and percentages to describe the prevalence of eclampsia and sexual violence by DHS countries. We also described the distribution of reported sexual violence by each covariate. We evaluated the prevalence of eclampsia and sexual violence across the levels of the covariates in the analysis using crosstabulations and computed the χ2 or Fisher exact and trend P value tests. Then, to evaluate the risk of suggestive eclampsia by ever subjected to sexual violence we computed unadjusted and adjusted odds ratios (OR) for each country and for the pooled sample. We used a logistic regression. For multivariable analysis, we adjusted for (maternal age, residence, wealth, maternal and partner education, access to ANC and institutional birth, decision making on own health, and parity) and explored the interactions between the occurrence of sexual violence and parity. Considering the lack of information on the exact timing of sexual violence, we conducted a sensitivity analysis restricting our study population to women who had their last live birth over the 12 months before the interview. Finally, we explored between and within countries heterogeneity for the pooled association between eclampsia and sexual violence and used a nonlinear mixed logistic random effect model to control for the within-country correlation [43]. Confidence interval were calculated using bootstrap technique, based on person-to-person variability (eg, Neyman-Pearson null hypothesis). We used Stata v13.1 SE (StataCorp LP, College Station, Texas, USA) [44] for statistical analysis. This study used existing data obtained from ORC Macro through formal request mechanisms. No additional ethical review for the secondary analysis was required since each country and the institutional review board of ORC Macro (Calverton, MD, USA) approved the DHS data collection procedures.
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