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Background: Intimate partner violence exposes women to a wide range of health problems that can either directly or indirectly lead to maternal death. Although in a number of studies intimate partner violence has been associated with inadequate utilization of antenatal care and skilled delivery care, in other studies no association has been found. Therefore, we aimed to comprehensively review the evidence, and quantify the strength and direction of the association between intimate partner violence and utilizing adequate antenatal and skilled delivery care services. Method: We systematically searched studies from MEDLINE, Embase, Psych INFO, CINAHL, and Maternity and Infant Care. Two independent reviewers screened the articles for eligibility. Quality and risk of bias in the articles were evaluated by using the Newcastle-Ottawa scale for observational studies. Pooled odds ratios and 95% confidence intervals were computed to estimate the association of intimate partner violence and antenatal care, and skilled delivery care. Random-effects models were used to allow for the significant heterogeneity that might possibly be found between studies. The degree of heterogeneity was expressed by using the I2 statistic. Results: The meta-analyses have shown that women who experienced intimate partner violence had 25% decreased odds (AOR = 0.75, 95%CI = 0.61, 0.92) of using adequate antenatal care than those who did not experience IPV. Similarly, women who experienced IPV had 20% decreased odds (AOR = 0.8, 95%CI = 0.69, 0.92) of using skilled delivery care compared to those who did not experience IPV. Conclusion: The meta-analyses indicated that experiencing intimate partner violence is associated with a lower likelihood of receiving adequate antenatal care and skilled delivery care. Both community-based and facility-based interventions that target the reduction of partner violence, and strictly implementing proven health facility-based counselling interventions, could aid in improving utilization of maternal health care services.
Registration: This systematic review and meta-analysis was registered on Prospero with the registration number CRD42017075543. Any peer reviewed observational studies (cohort, case–control, and cross-sectional studies) that assessed the association of IPV with antenatal care and skilled delivery care were included in this study. Observational studies that did not report the association of IPV with outcome variables by controlling possible confounders were excluded from the study. The review was not restricted by study setting or year of publication. This paper uses the WHO definition of IPV. According to WHO, IPV is defined as “any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship. Such behaviour includes acts of physical aggression, such as slapping, hitting, kicking and beating, as well as psychological abuse, such as intimidation, constant belittling and humiliation, and forced intercourse and other forms of sexual coercion. IPV can also include various controlling behaviours, such as isolating a person from their family and friends, monitoring their movements, and restricting their access to information or assistance” [19]. Therefore, the exposure for this study was women who reported an experience of at least one aspect of IPV, whether physical, sexual, emotional or control. Women with no history of any aspects of IPV were taken as the comparator group. The outcomes were antenatal care adequacy and skilled delivery care utilization. The 2002 WHO definition utilised by each of the studies included in the review was used to define antenatal care adequacy, where antenatal care services were considered adequate if women received four or more visits during pregnancy [16]. Skilled delivery care utilization was defined as having occurred if women received assistance during labour and delivery by a health professional with midwifery skills [2]. A comprehensive review of English language literature using the databases OVID MEDLINE, OVID Embase, OVID Psych INFO, OVID CINAHL, and OVID Maternity and Infant Care was performed. The searches were carried out from the inception of each database up to 05/09/2017. Search strategies were tailored to each database to employ the correct search terms. Where possible, both MeSH and free text terms with synonyms were used to increase identification of relevant studies. The following search terms were used to search for the available literature: (intimate partner violence OR partner abuse OR spouse abuse OR partner violence OR battered women OR domestic violence) AND (maternal health service OR maternal care service, OR antenatal care OR ANC OR prenatal care OR PNC OR pregnancy, OR pregnant women OR skilled birth attendant OR institutional delivery OR delivery at health facility). The search terms are available as Additional file 1. Two independent reviewers (AM, AG) screened the articles. First, the titles and abstracts of articles were screened to identify whether the articles were eligible for full text screening. Then, the two reviewers critically examined the full text of the articles based on the study eligibility criteria. Whenever there was a disagreement as to which article was to be included for full title and abstract screening as well as for full paper review, this was resolved through discussion. Two reviewers (AM, AG) independently extracted the data from eligible articles. The Joanna Briggs Institute (JBI) data extraction tool for observational studies was used to extract the data. The following variables were extracted: authors, year of publication, sample size, study design, study settings, types of violence, IPV assessment tools, IPV exposure period, main outcomes of the study, adjusted odds ratio of each outcome and confounder adjusted for the outcome. Quality and risk of bias in the articles were evaluated by using the Newcastle-Ottawa Scale (NOS) [20] for observational studies. Two reviewers (AM, AG) independently assessed the quality of each primary article. Any discrepancy in rating the quality was resolved through discussion. A system of points (stars) was given to the eligible categories. Since all studies included in the analysis were cross-sectional, the NOS with a total scale of six was used. A total NOS score of four or above out of six, as used by other studies [21, 22] was used to categorize articles as high quality. The individual studies were described using summary tables. The analysis was conducted using ProMeta version 3.0 software. Pooled odds ratios with 95% confidence intervals were computed to estimate the association of IPV with antenatal care adequacy and skilled delivery care utilization. Random-effects models were used to allow for the significant heterogeneity that might exist between studies. The degree of heterogeneity was expressed by using the I2 statistic. The odds ratio was considered significant if the confidence interval did not include 1.0. Similarly, I2 estimates were considered statistically significant at a P value of < 0.1. The risk of publication bias was evaluated by using Egger’s test. Some studies reported multiple estimates using different types of IPV on the same sample of participants. In order to avoid double-counting participants, in studies that reported on more than one aspect of partner violence, preference was given to one estimate that reported on combined IPV (if the study reported on combined IPV). However, in any study with multiple estimates that did not report on combined IPV, preference was given to types of IPV with the most precise estimate (with a narrow confidence interval) as used in the previous study [23]. We also carried out further analysis to precisely establish the relationship between each aspect of IPV and maternal health care services use. In addition, other confounders of IPV that were found to have an association with antenatal care adequacy and skilled delivery care were reviewed and discussed.
