INTERNAL EVALUTION FOR QT-II

Maternal Health-Related Sustainable Development Goals Targets Among Women Exposed to Intimate Partner
Violence

BY

Akshit Soni

21202219

MBA-II

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ABSTRACT

Health-related Sustainable Development Goal (SDG 3) aims to ensure healthy lives. This study investigates the in uence
of Intimate Partner Violence (IPV) on achieving maternal health related SDG3 targets among exposed women globally.

Methodology: This study used secondary data analysis of Domestic Violence Modules from the latest Demographic and
Health Surveys (DHS) of 40 countries. IPV was de ned by women ever exposed to emotional, physical, severe, or sexual
violence from the spouse. Achieving maternal health related SDG3 targets among women was measured by:
Proportion of births attended by skilled health personnel; Antenatal care (women received antenatal care eight or
more times from any provider); and the need for family planning satis ed with modern methods. The in uence of IPV
was estimated through adjusted OR after controlling for socioeconomic factors using binary logistic regression.

Results: Exposure to IPV was among one-third of the women (37%) mainly physical (29%) and emotional
(24%). Adjusted OR with 95%CI for the in uence of IPV on women’s utilization of skilled birth attendants was 0.81 (0.79-
0.83)); having eight or more antenatal care visits 0.61 (0.59-0.63); and the needs for family planning with modern
methods satisfied was 0.85 (0.83-0.87). Achievement of maternal health services was among 57% of the women.
Women exposed to IPV were less to achieve maternal health services (50% VS 61%) with adjusted OR 0.71; 95%CI:
0.70-0.73 and it was not confounded by the positive effect of socioeconomic factors.

Conclusion & Recommendation: Exposure to IPV had a statistically signi cant negative in uence on all the maternal
health related SDG3 services among women. Programs working in facilitating the achievement of the SDGs related
maternal health targets should include prevention of women’s exposure to IPV and support for those who are exposed
to it.

Introduction
Millennium Development Goals (MDGs), followed by the UN’s Sustainable Development Goals (SDGs) aimed at
improving health (1-6). Maternal Health-related SDGs are SDG 3.1 and 3.7 (7) To achieve the maternal health-related
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SDGs, The World Health Organization (WHO) identified three main reproductive and maternal health services (8) as the
following:

• Married or in-union women of reproductive age who need family planning satisfied with modern methods
(%).The unmet need for family planning provides a measurement of the capacity of women to achieve their desired
family size and birth spacing. (9,10)

• Antenatal care coverage - at least four visits (%): The World Health Organization has issued a new series of
recommendation to improve the quality of antenatal care to give women a positive pregnancy experience. The new
guidance increases the number of contacts a pregnant woman has with health providers throughout her pregnancy
from four to eight. (11).

• Births attended by skilled health personnel (%). Most maternal deaths are preventable with timelymanagement
by a skilled health professional (midwife, doctor, or nurse) working in a supportive environment (12, 13). There is no
shortage in the body of literature about the socioeconomic determinants in achieving these reproductive health
services in low- and middle-income countries (14-22)

On the other hand, Intimate Partner Violence (IPV) is a prevalent worldwide health problem. IPV is underreported and
underrecognized by healthcare professionals. IPV causes signi cant physical and psychiatric health problems with more
victimization among women, especially in low- and middle-income countries (23, 24).

There is a plethora of evidence-based studies on the vulnerabilities of women exposed to IPV to inadequate utilization
of maternal health care services and adverse maternal health outcomes (25-31).

As the present study focuses on the in uence of Intimate Partner Violence (IPV) on achieving maternal healthrelated
SDG3 targets among exposed women, it will investigate IPV's in uence on women’s utilization of these three
reproductive health services.

This study used secondary data analysis of Domestic Violence Modules of Demographic and Health Surveys (DHS),
which are nationally representative surveys that employ standardized questionnaires to collect extensive data from
women of reproductive age (15–49 years) in developing countries. The DHS obtain information on women’s
sociodemographic characteristics, their reproductive behaviors, birth history and maternal health service utilization
(32)

Datasets:
DHS collected data on women’s exposure to emotional, physical, and sexual violence for over 25 countries and growing
(33) using a domestic violence module (34). Individual Women’s Data – Individual Recode (IR) les of DHS have one
record for every eligible woman as de ned by the household schedule . It contains all the data collected in the women’s
questionnaire plus some variables from the household. The unit of analysis (case) in this le is the woman(35). In DHS
surveys, weights need to be applied when tabulations are made of statistics to produce the proper representation.

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When weights are calculated because of sample design, corrections for differential response rates are also made (36).
Weights were computed by dividing the sampling weighting variable (v005) by 1,000,000 and accounting for strati
cation and clustering.

Datasets from the standard DHS of 40 countries that collected domestic violence module using DHS questionnaire
version VII (37) starting from 2014 were downloaded in SPSS format and included in this study.

POPULATION
The 40 countries were from different economic levels as the following according to the most recent World Bank
economic GNI Per Capita classification.

Low-income economics (GNI per Capita $1,045 OR LESS):

Afghanistan (2015); Burundi (2016); Chad (2014); Congo Democratic Republic (2014); Ethiopia (2016); Gambia
(2019); Liberia (2019); Malawi (2015); Mali (2018); Mozambique (2015); Nepal (2016); Rwanda (2015); Sierra Leone
(2019); Tanzania (2016); Togo (2014); and Uganda (2016).

Lower-middle income economics (GNI per Capita $1,046 TO $4,095):

Angola (2015); Benin (2017); Cameroon (2018); Cambodia (2014); Egypt (2014); Haiti (2016); India
(2019); Kenya (2014); Mauritania (2019); Myanmar (2016); Nigeria (2018); Pakistan (2017); Papua New Guinea (2018);
Philippines (2017); Tajikistan (2017); Timor-Leste (2016); Zambia (2018); and Zimbabwe (2015).

Upper-middle income economics (GNI per Capita $4,096 TO $12,695):

Armenia (2016); Colombia (2015); Guatemala (2015); Jordan (2017); Maldives (2016); and South Africa
(2016).

Geographically, they presented countries from the following DHS regions (39): Sub-Saharan Africa; North Africa/West
Asia/Europe; Central Asia; South & Southeast Asia, and Latin America & Caribbean

VARIABLES
Intimate Partner Violence:

Exposure of Women to Intimate Partner Violence (IPV) was measured by counting the answers of yes for the four types
of violence (40). A new variable of IPV was coded from women exposure to at least one type.

Emotional violence was measured from the answer of yes to “Experienced any emotional violence” which counts the
answers of variables of “Ever humiliated by husband/partner”; “Ever threatened with harm by husband/ partner” and
“Ever insulted or made her feel bad by husband/ partner”.
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Physical violence was measured by answer of yes to question. “Experienced any less severe violence” which counts
the answers of from variables of “Ever been pushed, shook, or have something thrown by
husband/partner”, “Ever been slapped by husband/partner”, “Punched with st, or hit by something harmful by
husband/partner”, and “Ever had arm twisted or hair pulled by husband/partner”.

Severe physical violence was measured by answer of yes to question “Experienced any severe violence” which
counts answers of “Ever been kicked or dragged by husband/partner”, “Ever been strangled or burnt by
husband/partner” and “Ever been threatened with a knife /gun or other weapon by husband/partner”.

Sexual violence was by the answer of yes to “Experienced any sexual violence” which counts the answers of “Ever been
physically forced into unwanted sex by husband/partner”, “Ever been forced into other unwanted sexual acts by
husband/partner” and “Ever been physically forced to perform sexual acts respondent didn’t want to by
husband/partner”.

Socioeconomic determinants:

The socioeconomic determinants of exposure to IPV and utilization of reproductive health services were counted from
the following variables:

Women age: it was measured through the variable” Women age in 5 years groups” classi ed as ages 1519; 20-24;
25-29; 30-34; 35-39; 40-44; and 45-49 years old.

Residence: it was measured from variable “Type of place of residence” of Urban Vs. Rural residence
Economic level of household: It was measured from the “Wealth index” variable of DHS data categorizing economic
level into ve levels of poorest, poor, middle, richer, and richest.
Women’s Educational level: it was measured from the variable of “Highest educational level” of no education,
primary, secondary, and higher.
Women ‘s working status: The working status variable was computed from the answer of yes to variables of
“Respondent is currently working”.
Economic level of the country: it was measure through the World Bank countries classi cation

A scale of the socioeconomic determinants was computed from these variables. It was recoded as low, middle, and
high levels.

The proportion of married or in-union women of reproductive age who have their need for family planning satisfied
with modern methods was coded from the revised DHS variable of unmet needs for family planning (variable
626A). The unmet need for family planning is de ned as the percentage of women who do not want to become
pregnant but are not using contraception. Though the concept seems straightforward, the calculation is

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 extraordinarily complex and has changed over time. To address these issues, DHS revised the de nition of unmet
need in 2012 (41)
Antenatal care coverage: Having adequate antenatal care visits number was coded from the variable of number
of antenatal care visits to be 8 and more visits for the last child according to the new guidelines of WHO (11).
Births attended by skilled health personnel (%).Skilled birth attendant was computed from assisted delivery by a
doctor or nurse/midwife for the last birth.

A new variable was counted from the three maternal health services. It was dichotomized to those who achieved two
or the entire three versus those who were not achieving any or just one of the three.

DATA ANALYIS PLAN

Data analysis using SPSS version 24 was conducted, including descriptive statistics as frequencies and signifcance
tests (Odd Ratio with 95%Confidence Intervals). The StatCalc function of Epi-info software was used to estimate Chi-
Square for trend and related OR, 95%CI. The in uence of exposure to IPV was measured by the adjusted OR through
running binary logistic regression analysis controlling for socioeconomic determinants. The impact of IPV was also
measured through running significance test on the new coded variable of the utilization of maternal health services
among different countries

The valid number of observations was counted excluding those with answers of “Don’t know” to tackle the well-known
limitations of the cross-sectional study nature of DHS and recall bias.

Result and Discussion

The nal weighted data was from 290,825 women who responded to the domestic module questionnaire. Exposure to
emotional violence was among 24% of women; however, reached 50% in Papua New Guinea, followed by Sierra Leon
(46%). Less severe physical violence was among 29%; however, it was among 52% in Papua New Guinea, followed by
Afghanistan (50%). Severe violence was experienced by 11% of women, it was highest in Papua New Guinea (35%)
followed by Sierra Leon (29%). The exposure to sexual violence was among 9% of women, reaching 28% in Papua New
Guinea, followed by Burundi (26%). IPV was among 37% of women mostly as one type (17%) while only 3% were
exposed to the whole 4 types of violence. Global estimates published by WHO (41) indicated that about 1 in 3 (35%)
of women worldwide had experienced either physical and sexual intimate partner violence or non-partner sexual
violence in their lifetime. The results of this study con rmed the same prevalence of IPV in one-third of the studied
women. The most prevalent violent behaviors were slapping (25%), followed by insulting (18%), and pushing (16%).
While the least were burning, strangling, or threatening by gun/knife (less than 3% each).

The prevalence of IPV among countries as demonstrated in Fig 1 showed that it was highest in Papua New Guinea
(62%), followed by Sierra Leon (61%) and it was among 56% in Afghanistan, Liberia and Uganda. While it was lowest in
Armenia (14%) and Mauritania (19%).

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Socioeconomic determinants
As table 1 shows, IPV was more among middle-aged women, highest in the age group of 25-34 years old, and lowest in
the younger age group of 15-19 years old. IPV was more among women residing in rural areas. It shows the protective
influence of education against IPV. Despite that highly educated woman constituted 12% only; however, they were the
least to be exposed to IPV Vs those who were uneducated as they were the highest to be exposed to IPV. IPV was
higher among the poorest households and in low-income countries. Working women seem to be more exposed to IPV;
however, on further analysis of occupational categories, IPV was highest among women working as self-employed in
agricultural (47%) while it was lowest among women working in clerical (27%) and professional /managerial jobs (28%).
Table 1: Socioeconomic determinants percentage by IPV status

No IPV IPV OR 95%CI % of population

Age:
15-19 years 68.5 31.5 1.00 # 4.0

20-24 years 63.1 36.9 1.27 1.22-1.33 14.7

25-29 years 62.1 37.9 1.33 1.27-1.39 20.4

30-34 years 62.2 37.8 1,33 1.27-1.38 19.6

35-39 years 62.3 37.7 1.32 1.26-1.38 17.1

40-44 years 62.9 37.1 1.29 1.23-1.35 12.8

45-49 years 63.1 36.9 1.27 1.22-1.33 11.3

Residence:
Urban 66.4 33,6 1.00 # 38.3

Rural 60.5 39.5 1,29 1.27-1.31 61.2

Household economic level 58.9 41.1 1.00 # 20.2

Poorest Poorer 59.8 40.2 0.96 0.94-0.98 20.6

Middle Richer 61.6 38.3 0.89 0.87-0.91 20.4

Richest 64.1 35,9 0.80 0.78-0.82 20.1
70.3 29.7 0.61 0.59-0.62 18.8

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 Women’s educational level 55.8 44.2 1.00 # 28.3

No education Primary 58.4 41.6 0.90 0.88-0.92 25.8

Secondary Higher 66.8 33.2 0.63 0.62-0.64 34.1

78.0 22.0 0.36 0.35-0.37 11.8

Women ‘s working status

66.1 33.9 1.00 # 52.8
Not working Working
59.1 40.9 1.35 1.33-1.37 47.2

Economic level of the country:

Low income 52.9 47.1 1.00 # 28.9

Low-middle income 65.4 34.6 0.59 0.58-0.60 54.5

Upper-middle income 71.4 28.8 0.45 0.44-0.46 16.6

% 62.8 37.2 100.0

N= 290,825 # Reference

Socioeconomic scale

The socioeconomic scale ranged from 6-21 with median of 12. It was recoded to low (less than 10); middle (11-15) and
high (16+) levels. Most of the participants were of middle level (60%), while those in low level constituted 26% and
14% were in the high level. As g 2 shows, the IPV was highest among the lower level and decreased with higher
socioeconomic level. Higher level of socioeconomic level was protective from exposure to IPV (OR 0.54; 95%CI: 0.53-
0.55).

Papua New Guinea which has the highest prevalence of IPV is a low middle income country with GNI per capita $2,790
(42) and GINI Index of 41.9 (43). The Gini Index is a summary measure of income inequality. (44). A higher Gini index
indicates greater inequality, with high-income individuals receiving much larger percentages of the population's total
income. (45). Further analysis of its socioeconomic levels showed that most if its population (63%) live in the middle
level and 27% in the lower level with 10% only in the higher level. However, 91% of its population reside in rural areas,
and 78% of its women are either not educated (30%) or have primary level of education (48%). While Sierra Leon is a
low-income country with GNI per Capita $ 510 and GINI Index of 35.7 (46). The majority of its population are living in
the lower (41%) and middle (57%) socioeconomic levels. Most of its population (65%) live in rural areas and most of its
women (60%) are uneducated. This could shed light on the in uence of the socioeconomic countries in these two
countries having the highest levels of IPV.

Maternal Health-related SDGs targets among women

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Proportion of married or in-union women of reproductive age who have their need for family planning satis ed with
modern methods:

Unmet need for contraception, among women currently in union was among 16% of 261,142 women. Thus
84% of women had met needs of modern contraception. The highest unmet need was in Angola and Haiti (38% each)
followed by Togo (34%) and Liberia (33%). These are like unmet need estimates for these countries computed using
DHS STATcompiler (47). While met needs was highest in Colombia (93%), India (91%) and Zimbabwe (90%).

As table 2 shows. Met need for family planning was less among women exposed to IPV (82% Vs 85%) with adjusted
OR 0.85; 95%CI: 0,83-0.87). Higher socioeconomic level was a positive determinant for met needs of family planning
methods

:
Valid results from 155,123 women showed that 11% of them didn’t not have antenatal care visits at all during their
last pregnancy and the median and mode among others was 4 visits. Having adequate antenatal care visits number
for at least 8 antenatal visits for the last child was among 16 % only of women,

Having 8 or more visits was highest in the Maldives (83%), Jordan (73%) and Egypt (58%). While it was less than 1% at
Burndy, Rwanda, and Chad.

As table 2 shows, having 8 or more antenatal care visits was less among those exposed to IPV (12% Vs 19% with
adjusted OR: 0.61; 95%CI: 0. 59-0.63). Higher socioeconomic level had three times positive impact on having
antenatal care visits

Delivery assisted by skilled birth attendants

Valid responses from 154,524 women, showed that Skilled birth attendants (SBA) assisted in 72% of deliveries (mainly
as nurses/midwives 44%). Traditional birth attendants (TBA) assisted in 15% of deliveries, while about 12% of deliveries
were assisted by others as relatives or friends.

Delivery assisted by skilled birth attendants was universal (100%) in Armenia, Jordan, and the Maldives, all high middle
income countries. While it was lowest in Tanzania (13%), Chad (27%) and Ethiopia (30%).

As table 2 shows. Deliveries assisted by skilled health attendants were less among women exposed to IPV (68% Vs 74%)
with adjusted OR 0.81; 95%CI: 0,0.79-0,83). Higher socioeconomic level was a positive determinant for having assisted
deliveries through skilled birth attendants.

Variable Met need of Having eight or more Delivery assisted by Achievement of

contraception antenatal care visits skilled health maternal health
personnel services

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 0.85 (0.83- 0.61 (0.59-0.63) 0.81 (0.79-0.83) 0.71(070-0.73)
Exposure to IPV
0.87)
Socioeconomic 1.61 (1.58- 3.16 (3.08-3.25) 1.34 (1.33-1.35) 1.25(1.24-1.26)
level 1.64)

Constant 2.33 -3.52 -2.20 -2.11

The results showed that the negative influence of IPV on each of the three maternal health service is not confounded
by socioeconomic factors.

Achievement of maternal health services

The new variable of achievement of maternal health services showed that 12% only utilized the three services, 45%
utilized two of the three, and 33% utilized one only, while 10% did not use any of them. Thus 57% of the women
utilized maternal health services, while the rest 43% were considered not utilizing. Women exposed to IPV were less to
achieve maternal health services (50% VS 61%) with adjusted OR 0.71; 95%CI: 0.70-0.73 (Table 2) and it was not
confounded by the positive effect of socioeconomic factors. The negative in uence of IPV on the achievement of
maternal health services was in almost all countries. (Fig 3).

The strongest influence was in Colombia (OR 0.41; 95%CI: 0.37-0.46) then Myanmar (OR: 0.52; 95%CI: 0.400.66).
Colombia is a high middle income country with GNI per capita ($6,160) and GINI index 54.2 (48). It has a high
achievement of maternal health services (83%); however, women exposed to IPV (33%) have lower level of 74% only.
While Myanmar is a low-middle income country with GNI per Capita $1,140 and GINI Index of 30.7 (49). It has
achievement of maternal health services of 58%; less among those exposed to IPV (45%) despite that IPV is among
21% of its women.

Surprisingly, IPV had a positive effect on achievement of maternal health services in two countries: Chad (OR 1.32; 95%
CI: 1.08-1.61) and Mali (1.30; 95%CI: 1.13-1.53). Both countries are of low-income countries. Chad has GNI per Capita
$650 and GINI Index of 37.5 (50). It has IPV prevalence of 33% and achievement of maternal health among 17% only
which rises to 20% among those exposed to IPV. Its women were universally living in lower (54%) and middle (45%)
socioeconomic level; mostly in rural residence (79%) and in their majority they were either not educated (68%) or with
primary level of education (21%). Those women educated to primary level were the highest to be exposed to IPV
(44%); however, they were not the highest to achieve Maternal health services. On the other hand, Mali has a GNI per
capita of $870 and a GINI index of 36.1 (51). Almost half of its women (49%) achieve maternal health services which is
increased to 52% among those exposed to IPV. Women were universally living in low (51%) or middle (48%)
socioeconomic levels. Most of the women live in rural areas (79%) and are uneducated (72%) or have a primary level of
education (13%). Those with primary education were the highest to be exposed to IPV (54%); however, they were not
the highest to achieve Maternal health services. The available data does not explain this positive in uence of IPV on
the achievement of maternal health services Recommendation in these two countries and that calls for further study.

CONCLUSION
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Globally, one-third of women are exposed to Intimate Partner Violence (IPV). IPV in uenced their achievement of
Maternal health-related SDGs targets negatively as it lowered their utilization of Skilled Birth Attendants, having at
least eight ante-natal care visits, and having their met needs of modern contraceptive methods. The in uence was
statistically signi cant and not confounded by the socioeconomic factors. Programs working in facilitating the
achievement of the SDGs related maternal health targets should include prevention of women’s exposure to IPV and
support for those who are exposed to it.

a. Ethics approval and consent to participate:

Permission to download and use the data was obtained from Measure DHS Macro, Inc. The data used in this study was
anonymized before its use.

b. Consent for publication I consent for publication.

c. Availability of data and materials

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The data that support the Findings of this study are available from DHS website, but restrictions apply to the
availability of these data, which were used under approval for the current study, and so are not to be shared by the
author. The datasets in SPSS format were downloaded from DHS website for the following countries:

Afghanistan (2015): https://dhsprogram.com/data/dataset/Afghanistan_Standard-DHS_2015.cfm? ag=0

Angola (2015): https://dhsprogram.com/data/dataset/Angola_Standard-DHS_2015.cfm? ag=1
Armenia (2016): https://dhsprogram.com/data/dataset/Armenia_Standard-DHS_2016.cfm? ag=1
Benin (2017): https://dhsprogram.com/data/dataset/Benin_Standard-DHS_2017.cfm? ag=1
Burundi (2016): https://dhsprogram.com/data/dataset/Burundi_Standard-DHS_2016.cfm? ag=1
Cambodia (2014): https://dhsprogram.com/data/dataset/Cambodia_Standard-DHS_2014.cfm? ag=1
Cameroon (2018): https://dhsprogram.com/data/dataset/Cameroon_Standard-DHS_2018.cfm? ag=1
Chad (2014): https://dhsprogram.com/data/dataset/Chad_Standard-DHS_2014.cfm? ag=1
Colombia (2015): https://dhsprogram.com/data/dataset/Colombia_Standard-DHS_2015.cfm? ag=1
Congo Democratic Republic (2014): https://dhsprogram.com/data/dataset/Congo-Democratic-
Republic_Standard-DHS_2013.cfm? ag=1

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