Domestic violence and obstetric outcome among pregnant women in Ilorin, North Central Nigeria

Abstract

Pregnancy constitutes a period of heightened risk for domestic violence, which can be physical, sexual, psychological, or emotional. A woman may be at risk irrespective of race, age, socioeconomic status, or educational level [1]. The abdomen is the most common target for physical violence [1]. Women who experience violence during pregnancy have a higher risk of pregnancy loss, preterm delivery, low birth weight neonates, premature rupture of membranes, stillbirth, and increased likelihood of cesarean delivery [1]. The main objective of the present study was to investigate pregnancy outcomes among women who had experienced domestic violence compared with women who had not been abused. The study was a prospective case–control study conducted at the Obstetrics and Gynecology department, University of Ilorin Teaching Hospital, Ilorin, Nigeria, from January 1 to June 30, 2012. All pregnant women attending the prenatal clinic were informed about the study and those who provided written informed consent were screened for domestic violence using a modified version of the Abuse Assessment Screen [2]. Monogamous families had 1 wife and polygamous families had 2 or more wives. The sample size was determined by the formula for comparison of groups and the sampling method was purposive sampling. Pregnant women recruited to the study were required to affirm or refute whether they had experienced physical, sexual, emotional, or psychological violence during the preceding year or in the index pregnancy that had been perpetrated by an intimate partner. Physical violence included beating or using objects with intent to hurt, while sexual violence included unwanted fondling or forced sex. Emotional or psychological abuse included verbal abuse, humiliation, and isolation. The control group consisted of pregnant women who had not experienced domestic violence matched for parity, age, family type, education level, history of preterm birth, smoking, and ultrasound scan for exclusion of fetal congenital abnormalities. Women with previous uterine surgeries were excluded from the study. Maternal outcome measures included preterm labor or delivery, operative vaginal or cesarean delivery, puerperal pyrexia, breastfeeding problems, anxiety, and depression. Presentation with cervical dilatation greater than or equal to 8 cm was termed late presentation. All instrumental deliveries were performed by the same individual. Neonatal outcomes included prematurity, low birth weight, birth asphyxia, intrauterine fetal death, and perinatal mortality. Ethical approval was obtained from the ethics and research committee of the University of Ilorin Teaching Hospital before commencing the study. Data were analyzed using SPSS version 18 (IBM, Armonk, NY, USA). P < 0.05 was considered statistically significant. A total of 200 pregnant women were included in the study, comprising 100 women who had experienced domestic violence (subjects) and 100 pregnant women who had not (controls). The age range for both groups was 18–42 years (mean 30.18 ± 4.78 years). For other variables, comparisons between the subject and control groups were: 82% vs 89% monogamous families, 25% vs 28% primiparity, 16% vs 12% late booking, and 96% vs 97% married couples. The perpetrator was the woman's husband in 96% of cases of domestic violence. Women who had experienced domestic violence were significantly more likely to have preterm labor (P = 0.037), instrumental vaginal delivery (P = 0.024), cesarean delivery (P < 0.001), breastfeeding problems (P = 0.015), postpartum depression (P < 0.001), and anxiety disorders (P = 0.008) (Table 1). The neonates of the subject group had statistically significant low birth weight (P < 0.001), and higher rates of birth asphyxia (P < 0.001) and neonatal death (P = 0.008) compared with neonates of the control group (Table 2). All instrumental vaginal deliveries were performed because of a prolonged second stage of labor. Cesarean deliveries were performed for fetal distress in 52% compared with 27% of the subject and control groups, respectively. Among the subject group, 38% presented late in labor compared with 16% in the control group. In the present study, the prevalence of domestic violence in pregnancy was 50% and husbands were the most common perpetrators. The violence was unrelated to sociodemographic parameters. Domestic violence was a marker for adverse maternal and neonatal outcomes with statistical significance. The prevalence of domestic violence in the present study was higher than the prevalence of 28% reported by Ameh and Abdul [3] in Nigeria, indicating a rising trend in domestic violence. The finding that husbands were the most common perpetrators paralleled a study conducted in Abuja, Nigeria [4]. The present study, like that of Ezechi et al. [5], reported no association between domestic violence and sociodemographic characteristics, which further emphasizes its pervasive effect across all sociodemographic groups. The adverse maternal outcomes reported in the present study were similar to reports by other researchers [6], with higher rates of instrumental vaginal and cesarean deliveries needed to expedite delivery because of fetal distress due to premature rupture of membranes and preterm labor. The adverse neonatal outcomes were consistent with previous reports of adverse neonatal outcome as a complication of domestic violence in pregnancy [6]. The pathway of the direct effect of physical trauma from domestic violence encountered during pregnancy and leading to adverse obstetric outcome [6] was not applicable in the present study, while the indirect pathway of late onset of prenatal care, late presentation in labor, and physical and emotional deprivation appear to be more relevant [6]. In conclusion, domestic violence is prevalent in this environment, appears to be increasing, and is a marker for adverse pregnancy outcomes. Routine screening for domestic violence during prenatal booking is recommended to identify vulnerable women, interrupt the cycle of abuse, and prevent adverse pregnancy outcomes. The authors have no conflicts of interest.