Maternal exposure to intimate partner violence and uptake of maternal healthcare services in Ethiopia: Evidence from a national survey

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Study Justification:
This study aims to explore the association between maternal healthcare seeking and exposure to intimate partner violence (IPV) among Ethiopian women. It is important to understand this association because women exposed to IPV often face barriers in accessing maternal health care services due to stigma and other social problems. By examining this association, the study can provide valuable insights into the impact of IPV on maternal health outcomes and inform the development of interventions to improve women’s access to maternal healthcare services.
Highlights:
– The study analyzed data from the 2016 Ethiopian Demographic and Health Survey (EDHS) to explore the association between IPV and maternal healthcare utilization.
– The analyses included 2836 currently married women with one live birth who participated in the domestic violence sub-study.
– The study found that exposure to emotional IPV was associated with poor uptake of maternal healthcare services, specifically in terms of antenatal care utilization.
– There was no significant association between IPV and utilization of health facility delivery.
– The study also examined the moderation effects of education and wealth status on the association between IPV and maternal healthcare service utilization.
Recommendations:
Based on the findings of the study, the following recommendations can be made:
1. Interventions should be developed to address the impact of emotional IPV on women’s uptake of maternal healthcare services. These interventions should focus on providing support and resources to women who have experienced emotional IPV.
2. Efforts should be made to improve women’s access to antenatal care services, particularly for those who have experienced emotional IPV.
3. Further research is needed to explore the reasons behind the lack of association between IPV and health facility delivery, and to identify potential interventions to address this issue.
4. Policy makers should consider the role of education and wealth status in moderating the association between IPV and maternal healthcare service utilization. Efforts should be made to improve educational opportunities and economic empowerment for women, as these factors can enable women to counteract the impact of IPV on their access to healthcare.
Key Role Players:
To address the recommendations, the following key role players may be needed:
1. Government agencies responsible for healthcare policy and implementation.
2. Non-governmental organizations (NGOs) working on women’s rights and healthcare.
3. Healthcare providers and professionals.
4. Community leaders and organizations.
5. Researchers and academics specializing in gender-based violence and maternal health.
Cost Items:
While the study does not provide actual cost estimates, the following cost items may need to be considered in planning the recommendations:
1. Funding for the development and implementation of interventions to address the impact of emotional IPV on maternal healthcare utilization.
2. Resources for improving access to antenatal care services, such as training healthcare providers, establishing and maintaining healthcare facilities, and providing transportation for women.
3. Investments in education and economic empowerment programs for women, including scholarships, vocational training, and microfinance initiatives.
4. Support for awareness campaigns and community outreach programs to promote women’s rights and raise awareness about the impact of IPV on maternal health.
Please note that these cost items are provided as examples and may vary depending on the specific context and resources available.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study utilized a nationally representative survey and employed multilevel logistic regression analyses to explore the association between intimate partner violence (IPV) and maternal healthcare utilization in Ethiopia. The study also considered potential moderators such as education and wealth status. However, the abstract does not provide specific details about the statistical significance of the associations found, except for one significant association between emotional IPV and adequate use of antenatal care. To improve the evidence, the abstract could include more information about the effect sizes, confidence intervals, and p-values for the associations examined. Additionally, it would be helpful to provide a brief summary of the main findings and their implications for policy and practice.

Background Women exposed to Intimate Partner Violence (IPV) often do not utilize maternal health care optimally both because of stigma and other social problems. The current study aims to explore an association between maternal healthcare seeking and violence exposure among Ethiopian women and to assess if educational attainment and wealth status moderate this association. Methods The analyses included 2836 (weighted) currently married women with one live birth. We focus on the five years preceding the 2016 Ethiopian Demographic and Health Survey (EDHS) who participate, in the domestic violence sub-study. Exposure was determined by maternal reports of physical, emotional, sexual IPV or any form of IPV. The utilization of antenatal care (ANC) and place of delivery were used as proxy outcome variables for uptake of skilled maternal healthcare utilization. Women’s education attainment and wealth status were selected as potential moderators, as they can enable women with psychological and financial resources to counteract impact of IPV. Multilevel logistic regression analyses were used to explore the association between spousal IPV and maternal health outcomes. Moderation effects by education and wealth status were tested, and the data stratified. Using statistical software Stata MP 16.1, the restricted maximum likelihood method, we obtained the model estimates. Results About 27.5% of the women who reported exposure to any form of IPV had a health facility delivery. While 23.4% and 22.4% visited four or more antenatal care services among mothers exposed to emotional IPV and sexual IPV, respectively. After adjusting for potential confounding factors, only the association between maternal exposure to emotional IPV and adequate use of ANC was statistically significant (OR = 0.73, (95% CI:0.56-0.95)). But we found no significant association between IPV and utilization of health facility delivery. Some moderation effects of education and wealth in the association between IPV and maternal healthcare service utilization outcome were found. Conclusion Exposure to emotional IPV was associated with poor uptake of maternal health care service utilization for married Ethiopian women. While developing interventions to improve women’s maternal healthcare service use, it is crucial to consider the effects of socio-economic variables that moderate the association especially with the intersection of IPV.

The publically available data of the fourth nationally representative survey of the 2016 Ethiopia Demographic and Health Survey (EDHS) was collected between January–June 2016. The full details of the data collection methods and procedures as well as the standards for protecting the privacy of study participants have been published [13]. IPV information for ever-married women age 15–49 ever reporting exposure of spousal emotional, physical, or sexual violence was collected using a modified and abbreviated version of the Revised Conflict Tactics Scales (CTS2) [30]. After excluding missing values, a total of 3061 (unweighted) ever-married women in reproductive age were considered in this study [13]. Special domestic violence weights were used to make the survey data on violence nationally representative accounting for non-response [31]. The final study sample was further limited to those who were currently married and had at least one live birth in the five years preceding the survey (weighted, n = 2836). The analyses in the current study address two maternal healthcare binary outcomes: (1) adequate antenatal care (ANC) use; categorized into four or more visits (≥4) and less than four visits (<4, this included women with no visit), in accordance with the 2002 WHO ANC model [32], which was recommended by the Ethiopian Federal Ministry of Health (FMoH), at the time of initiating this study (This is not the current recommended ANC protocol by WHO which is based on WHO’s 2016 ANC Model prescribing a minimum of eight contacts.) and (2) place of delivery, categorized as home birth or birth at a health facility. The predictor variables were reported as exposure to emotional, physical, sexual IPV or any type of IPV. In the current study, emotional IPV is a composite binary variable based on responses to three questions: Had the husband ever: (1) said or did something to humiliate her in front of others; (2) threatened to hurt or harm her or someone she cared about; or (3) insulted or made her feel bad about herself, with yes (experiencing at least one of these); and (not experiencing any), [13, 28, 33]. Similarly, physical IPV is a composite binary variable based on women’s responses to the questions about whether the husband ever had done any of the seven following acts: (1) push, shake, or throw something; (2) slap; (3) twist arm or pull hair; (4) punch with fist or with something that could be harmful; (5) kick, drag, or beat her up; (6) tried to choke or burn her; (7) threaten or attacked with any material to deliberately hurt her at one point in lives [13, 28, 33]. Sexual IPV was, responding yes to any of these three questions: (1) physically forced to have sex; (2) forced to other sexual acts; (3) forced by threats when she did not want to [13, 28, 33]. Lastly, any IPV, was a composite dichotomous summary measure created from 13 questions (emotional IPV: 3, physical IPV: 7, and sexual IPV:3) to capture the women’s ever experience of any IPV (emotional, physical and/or sexual), grouped as: Yes (‘yes’ responses to any of these 13 questions), and No (‘no’ responses to all of the 13 questions). Based on the literature, two variables–women’s education level and household wealth status were considered as potential moderators [27, 28]. Education level of the woman was based on: the highest level of education attained by the respondent and grouped into two: as None, or Primary and above. Household wealth index; a composite index of household possessions, assets, and amenities, derived using principal component analysis (PCA), and ranked as poorer; poor; middle; rich; and richest. For our analysis, we re-categorized wealth into three categories (poor, middle, rich) [34, 35]. Based on the current literature, we included several potential confounding variables. The woman’s self-reported age at the time of the survey, was categorized as younger (15–24 years); middle (25–34 years) and older (35–49 years) as age affects health seeking behaviors, [36]; the order of the last birth closes to the time of the survey; education level of the partner reported as none, primary and above; exposure to mass media (composite variable based on the access to and frequency of use of radio and/or television at least once a week), [37]; decision-making autonomy in making three household decisions (access to health care; large household purchases; and freedom to visit families and relatives), grouped into, low autonomy (no participation in any decision making), medium autonomy (participation in 1 or 2) and high autonomy (participation in all decision making); attitude towards wife beating was created using scenarios: (1) she burns the food; (2) she argues with him; (3) she goes out without telling him; (4) she neglects the children and (5) she refuses to have sex with him. A woman was regarded as accepting violence if she said it was justified for any of these five reasons and as rejecting if she reported that beating was not justified for any reasons [38], and the place of residence at the time of the survey categorized as urban or rural. The regions were defined according to the FMoH as agrarian (Tigray, Amhara, Oromia and SNNPR), pastoralist (Somali, Afar, Gambella, and Benishangul Gumuz regions) and city dwellers (Addis Ababa, Dire Dawa, and Harar). We used bivariate analyses to describe the characteristics of the women in relation to the outcome of interest and each type of IPV along with the Pearson Chi-square (X2) test of independence to examine whether there were any significant differences in the sociodemographic characteristics, and the associated p-value calculated. Sampling weights were applied for the data when we computed both the bivariate and multivariate analysis to manage the unequal probability of selection between the strata defined by geographical location and for non-responses. We fitted separate random-effects multilevel logistic regression models, for each outcome of interest (ANC and delivery care) using only the variables that were significantly associated with each outcome and type of IPV in the bivariate models. We used a binary logistic multilevel regression model, as the data was clustered at the survey level (2836 women nested in 626 clusters). Univariate logistic regression was performed to estimate the crude odds ratios (COR), (See, S1 Table). And the 95% confidence intervals (95%CI) of facility delivery or not, and if she had at least four ANC visits or not. Potential predictors and confounders significantly associated with the outcome variables in the univariate analysis were entered in the multilevel logistic regression analysis. We conducted four separate fully adjusted models for each type of IPV (emotional, physical, sexual, and any type of violence) for each outcome variable while controlling for confounders to identify the association between spousal IPV on the use of maternal healthcare services. To assess any moderating effect of education and/or wealth in the association between exposure to spousal IPV and maternal healthcare services, interactions were checked (interaction between IPV and education/wealth). Finally, analyses of the association between exposure to spousal IPV and maternal healthcare services were stratified by level of education and household wealth status. Prior to the multivariate regression analysis, multi-collinearity was checked using variance inflation factors (VIF) which indicates that there was no multi-collinearity since all variables have VIF <2 and all were considered for the subsequent analysis. In addition, we computed an estimate of intra-cluster correlation coefficient (ICC), which described the amount of variability in the response variables attributable to differences between the clusters. We examined the model fit measured using the Akaike information criteria (AIC). A lower AIC value represents a better model fit [39]. All the statistical analyses were performed using complex sample analysis procedure to allow for adjustment for the sampling weight, stratification, the cluster sampling design, and the calculation of standard errors of the large survey data [31, 40]. We conducted tests for correlations among the types of IPV. IBM SPSS 26.0 was used for data preparation and the model parameter estimates were obtained in the statistical software Stata MP 16.1 using the restricted maximum likelihood method (REML). The level of significance was set at 0.05. The study adhered to national and international ethical guidelines for biomedical research involving human subjects [41], including the Helsinki declaration. The study protocol was reviewed and approved by the Regional Committee for Medical and Health Research Ethics (Code number: 2016/967/REK sør-øst A) and the Norwegian Centre for Research Data (Code number: 48407) at the University of Oslo. Our team also requested permission and access to the data from the CSA in Ethiopia and Inner City Fund (ICF) international by registering online on the website www.dhsprogram.com [42] and submitting the study protocol by highlighting the objectives of the study as part of the online registration process, (See, S1 File). The ICF Macro Inc, removed all information that could be used to identify the respondents; hence, anonymity of the data was maintained.

Based on the information provided, here are some potential innovations that could be recommended to improve access to maternal health:

1. Awareness campaigns: Develop targeted awareness campaigns to educate women about the importance of maternal healthcare services and the potential risks of intimate partner violence (IPV) on maternal health. These campaigns can be conducted through various channels such as radio, television, and community outreach programs.

2. Training healthcare providers: Provide training to healthcare providers on identifying and addressing IPV among pregnant women. This can include training on how to ask sensitive questions, provide support, and refer women to appropriate resources for help.

3. Integrated services: Implement integrated services that combine maternal healthcare and IPV support. This can involve establishing partnerships between healthcare facilities and organizations that specialize in addressing IPV, ensuring that women receive comprehensive care and support in a safe and confidential environment.

4. Mobile health (mHealth) interventions: Utilize mobile technology to deliver maternal health information and support to women, including those who may be experiencing IPV. This can include text message reminders for antenatal care appointments, access to educational resources, and helpline services for women in need of immediate assistance.

5. Community-based interventions: Engage community leaders, religious leaders, and local organizations to raise awareness about IPV and maternal health. These interventions can involve community dialogues, support groups, and community-led initiatives to address the social and cultural factors that contribute to IPV and hinder access to maternal healthcare.

6. Economic empowerment programs: Implement programs that aim to empower women economically, as financial independence can help women overcome barriers to accessing maternal healthcare services. This can include vocational training, microfinance initiatives, and income-generating activities.

7. Policy and legal reforms: Advocate for policy and legal reforms that protect women from IPV and ensure their access to maternal healthcare services. This can involve strengthening laws against IPV, promoting gender equality, and allocating resources for maternal health programs.

It is important to note that these recommendations are based on the specific context of the study in Ethiopia and may need to be adapted to suit the local context and resources available in other settings.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health based on the provided description is to develop interventions that address the intersection of intimate partner violence (IPV) and socio-economic variables.

1. Raise awareness: Develop educational campaigns to raise awareness about the negative impact of IPV on maternal health and the importance of seeking maternal healthcare services. These campaigns should target both women and men, aiming to change attitudes and behaviors related to IPV.

2. Strengthen support systems: Establish support systems for women experiencing IPV, including counseling services, helplines, and safe spaces where women can seek help and support. These support systems should be easily accessible and provide comprehensive assistance, including legal, medical, and psychosocial support.

3. Improve healthcare provider training: Provide training to healthcare providers on identifying and responding to IPV among pregnant women. This training should include strategies for creating a safe and supportive environment for women to disclose their experiences of violence and appropriate referral pathways for further assistance.

4. Enhance economic empowerment: Implement programs that promote economic empowerment for women, such as vocational training, microfinance initiatives, and income-generating activities. These programs can help women gain financial independence and reduce their vulnerability to IPV.

5. Strengthen legal frameworks: Advocate for the implementation and enforcement of laws and policies that protect women from IPV and ensure their access to maternal healthcare services. This includes laws against domestic violence, sexual assault, and discrimination, as well as policies that support women’s reproductive rights.

6. Collaborate with community leaders and organizations: Engage community leaders, religious leaders, and local organizations in efforts to address IPV and improve access to maternal health. These stakeholders can play a crucial role in challenging social norms that perpetuate violence and promoting positive attitudes towards women’s health.

By implementing these recommendations, it is possible to develop innovative approaches that address the complex factors contributing to limited access to maternal healthcare services among women experiencing IPV in Ethiopia.
AI Innovations Methodology
Based on the provided description, the study aims to explore the association between maternal healthcare seeking and exposure to intimate partner violence (IPV) among Ethiopian women. The study also aims to assess if educational attainment and wealth status moderate this association. The methodology used in the study includes the following steps:

1. Data Collection: The study utilizes publicly available data from the fourth nationally representative survey of the 2016 Ethiopia Demographic and Health Survey (EDHS). The data was collected between January and June 2016 using standardized methods and procedures to ensure privacy protection.

2. Sample Selection: The study includes currently married women with at least one live birth in the five years preceding the survey. The final sample size is 2836 weighted participants.

3. Measurement of IPV: IPV information is collected using a modified and abbreviated version of the Revised Conflict Tactics Scales (CTS2). Women’s exposure to emotional, physical, sexual IPV, or any form of IPV is determined based on their responses to specific questions.

4. Outcome Variables: The study focuses on two maternal healthcare outcomes: (1) adequate antenatal care (ANC) use, categorized as four or more visits and less than four visits, and (2) place of delivery, categorized as home birth or birth at a health facility.

5. Potential Moderators: Women’s education level and household wealth status are considered as potential moderators, as they may influence the association between IPV and maternal healthcare utilization.

6. Statistical Analysis: Multilevel logistic regression analyses are used to explore the association between spousal IPV and maternal health outcomes. Separate models are fitted for each type of IPV, controlling for potential confounding factors. Interactions between IPV and education/wealth are checked to assess any moderating effects.

7. Stratified Analysis: The association between IPV and maternal healthcare services is stratified by level of education and household wealth status to further examine the potential moderating effects.

8. Model Fit and Interpretation: Model fit is assessed using the Akaike information criteria (AIC), with lower values indicating better fit. Odds ratios (OR) and 95% confidence intervals (CI) are calculated to estimate the association between IPV and maternal healthcare outcomes.

9. Ethical Considerations: The study adheres to national and international ethical guidelines for biomedical research involving human subjects, including the Helsinki declaration. Ethical approval is obtained from the relevant committees, and data privacy is ensured.

In summary, the methodology involves analyzing the publicly available data from the 2016 Ethiopia Demographic and Health Survey to explore the association between IPV and maternal healthcare utilization. The study utilizes multilevel logistic regression analyses and considers potential moderators to assess the impact of IPV on maternal health outcomes.

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