Introduction

Intimate partner violence (IPV), also referred to as intimate partner abuse, is any behaviour by an intimate partner that causes physical, sexual or psychological harm, and includes physical aggression, sexual coercion, psychological abuse and controlling behaviour [1]. A systematic review and meta-analysis of global data reports an estimated overall prevalence of intimate partner violence (IPV) during pregnancy to be 25% [2]. The IPV prevalence in pregnancy in Asia, Europe, North America and South America are reported to be 32.1%, 5.1%, 20.4%, and 25.6% respectively [2]. In Sub-Saharan Africa (SSA), the pooled prevalence of IPV in pregnancy is 34.9% [3] which ranks higher than the global prevalence. In Ghana, data from the Demographic and Health Survey (DHS) shows that 5% of pregnant women experience physical IPV during pregnancy [4]. In a tertiary care facility in Ghana, the prevalence of domestic violence by an intimate partner was reported to be 31.1% during pregnancy [5]. There is a high prevalence of IPV among pregnant women [6–8] which could be due to their vulnerability and dependence, both physically and emotionally, on their partners [6]. Pregnancy indicates a period of heightened vulnerability to IPV due to changes in women’s circumstances [9].

Studies allude to inequalities in IPV across low- and middle-income countries [10, 11]. It has been reported that younger pregnant women from impoverished and less empowered backgrounds are more susceptible to IPV [11]. Pregnant women are more likely to be in intimate relationships than non-pregnant people, which increases their likelihood of experiencing IPV [12]. Furthermore, IPV in pregnancy can be significantly influenced by the nature of the pregnant woman’s relationship with her partner [12]. The existing evidence, however, does not reflect the full burden of the problem of IPV during pregnancy [6].

Intimate partner violence during pregnancy is found to be directly related to adverse pregnancy outcomes and both fatal and non-fatal health consequences in both pregnant women and their offspring [4]. Data from the World Health Organization (WHO) has shown that IPV is linked to a two-fold rise in induced abortions, as well as a 16% increase in low-birth-weight newborns and a 43% increase in pre-term births [13]. It is reported that the risk of low birth weight and preterm birth increases when pregnant women are exposed to multiple forms of IPV [14].

Economic hardships and resource scarcity have been found to create a context for conflict and abuse between partners [15]. Intimate partner violence is strongly correlated with adversity, especially poverty, during the antenatal period [16]. There are sociodemographic and behavioural factors that increase the risk of IPV in pregnant women as well as obstetric factors which include obstetric history and whether the pregnancy was planned or not [17–19]. In many primary care settings in Ghana, there appears to be limited published literature on intimate partner violence among pregnant. An analysis of factors associated with IPV in pregnancy in a resourced-constrained setting like Ghana and in primary care practice, which is the first contact between pregnant women and the healthcare delivery system, provides an opportunity to identify these factors and influence policy measures aimed at addressing IPV which is regarded as a public health concern globally [13].

Primary care providers are well-positioned to identify and address at-risk behaviour for IPV promptly through quality patient-physician interactions built on trust [20]. Through strategies for identifying IPV including screening and case finding in patients with suspected signs or symptoms presenting at the primary care level, management can be instituted [21]. This study, therefore, sought to determine the factors associated with IPV among pregnant women attending a primary care antenatal facility, using a cross-sectional design. The study also sought to determine the prevalence and patterns of IPV among pregnant women at the study site. Furthermore, findings from this research would contribute to the data and body of knowledge on the associated factors of IPV among pregnant women, especially in primary care settings in low-resource countries.

Materials and methods

Results

Out of the total sample size, data from 269 consenting participants was used for the analysis resulting in a response rate of 94.7%. The age of participants ranged from 17 to 43 years with a mean age of 29 years (SD±5.08) years. The peak age group was 25 to 34 years, accounting for 65.1% of the participants. The majority (66.5%) of the participants were married. Among those who were not married, 57 (21.2%) were single and 33 (12.3%) were cohabiting. The most prevalent type of marriage was monogamy which constituted 95% of married participants. Most participants (76.9%) were employed, and the most common level of education among them was secondary school, which accounted for 63.6% of the total. The socio-demographic characteristics of all 269 participants recruited for the study are shown in Table 1. The overall prevalence of IPV was 11.2%. The prevalence of emotional abuse, harassment, physical abuse, sexual abuse and severe combined abuse from the composite abuse subscales were 12.3%, 13.0%, 8.2%, 3.3% and 8.9% respectively.

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Table 1. Socio-demographic characteristics of study participants.

https://doi.org/10.1371/journal.pone.0310169.t001

Tables 2 and 3 show the obstetric characteristics and behavioural factors of participants respectively. The majority (79.5%) of the participants were multigravida compared to 20.5% of primigravida women. Furthermore, 34.6% had pregnancies that were unplanned at the time of the study. Booking for the antenatal clinic for almost all of the participants was done in either the first or second trimester of the current pregnancy. Concerning pregnancy outcomes of previous pregnancies, 90 (33.5%) had a history of miscarriage or abortion, 15 (5.6%) had a history of stillbirth, and 6 (2.2%) had a history of preterm delivery. The behavioural characteristics of the partners of participants showed that cigarette smoking in the last 12 months and partner’s use of recreational drugs in the last 12 months was 1.5% each. Partner alcohol use in the last 12 months was also 27.5% of all the 269 participants.

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Table 2. Clinical (Obstetric) characteristics of participants.

https://doi.org/10.1371/journal.pone.0310169.t002

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Table 3. Behavioural characteristics of study participants.

https://doi.org/10.1371/journal.pone.0310169.t003

The sociodemographic factors associated with IPV in bivariate analysis were participants’ employment status (χ2 = 36.221, p = 0.000), employment status of their partners (χ2 = 7.291, p = 0.007), and partner’s highest level of education (χ2 = 13.038, p = 0.005). The obstetric or clinical factors associated with IPV in bivariate analysis were unplanned pregnancy (χ2 = 63.901, p = 0.000), the gestational age at which the participants presented for booking (χ2 = 11.183, p = 0.004), and a history of stillbirth (χ2 = 3.859, p = 0.049). The behavioural factors associated with IPV on bivariate analysis were participants’ experience of conflict or dissatisfaction in the relationship (χ2 = 154.799, p = 0.000), participant’s past experience of violence committed by parents or another family member (χ2 = 26.524, p = 0.000), alcohol consumption by participants (χ2 = 52.766, p = 0.000) and partner alcohol consumption (χ2 = 52.766, p = 0.000). Among the participants, there was a statistically significant association between a positive screen for depression and IPV. (χ2 = 106.217, p = 0.000). The chi-square test is provided in the S1 Table (Supporting information).

Multiple logistic regression analysis in Table 4 shows the factors associated with IPV identified among the participants. The adjusted regression analysis demonstrated that pregnant women who were employed had reduced odds (84%) of experiencing IPV compared to unemployed pregnant women. [AOR = 0.16 (95% CI = 0.05–0.47), p<0.01]. For women who have experienced violence committed by parents or family members in the past, the odds of experiencing IPV is 4.9 times as great as the odds of pregnant women without a previous experience of violence [AOR = 4.9 (95% CI = 1.06–22.96), p<0.05]. Pregnant women who used alcohol in the last 12 months had 7.8 times the odds of experiencing IPV compared to pregnant women who didn’t take alcohol. [AOR = 7.8 (95% CI = 1.63–37.42), p = 0.01]. Furthermore, women whose partners used alcohol in the last 12 months had 10 times the odds of experiencing IPV compared to women whose partners didn’t use alcohol [AOR = 10.0 (95% CI = 3.22–31.26), p<0.001].

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Table 4. Factors associated with intimate partner violence among pregnant women.

https://doi.org/10.1371/journal.pone.0310169.t004

Discussion

The prevalence of IPV among this population of pregnant women was found to be 11.2%. The prevalence of harassment, emotional/psychological abuse, severe combined abuse, and physical abuse from the CAS subscales were 13.0%, 12.3%, 8.9%, and 8.2%, respectively. The least prevalent form of violence was sexual violence which occurred in 3.3% of the participants. The factors found to be associated with IPV among this population of pregnant women were the employment status of the women, the experience of violence committed by parents or another family member in the past and current alcohol use by pregnant women and their partners.

The overall prevalence of IPV among pregnant women in this study was 11.2% which is lower than the global prevalence of 25.0% reported by Román-Gálvez et al in their systematic review and meta-analysis [2]. This prevalence is lower than those found in studies done in Asia (32.1%), North America (20.4%) and South America (25.6%) but higher than that of Europe (5.1%) [2] The prevalence of 11.2% in this study is slightly lower than the prevalence of 15% reported by Field et al in South Africa [16]. Differences in the sociocultural acceptance of violence against women and intimate partner violence (IPV) may be linked to the observed variations in the geographical distribution of IPV [2]. For instance, in many African social contexts such as Ghana, issues about marital conflict and abuse in marriage are hardly discussed, thus there is the possibility of under-reporting of IPV.

Studies within the African region have reported higher prevalence rates such as those by Adebowale et al Nigeria (24.8%) [28]; Fekadu et al and Azene et al (Ethiopia)–58.7% and 41.1% respectively; [7, 29] all of whose study settings were hospital-based within a secondary or tertiary facility. Since tertiary and secondary level facilities receive referrals from other facilities for further management, the variation and higher occurrence may be related to the differences in the antenatal clinic settings. Furthermore, cases of IPV may also be included in these referrals to secondary or tertiary facilities. It is known that the attitude of pregnant women towards violence has an impact on how accurately they record their experiences, hence the prevalence of IPV in this study may potentially be underestimated. Misreporting is possible due to ethical and social difficulties surrounding IPV and the sensitive nature of this topic [4].

Even though emotional/psychological violence in this study is the most common type of IPV, its prevalence (12.3%) is lower than the prevalence of emotional violence (18.7%) reported by Román-Gálvez et al. [2]. Generally, IPV rates were highest in Africa, except for psychological IPV which was greater in North America [2]. The prevalence rate of psychological IPV in pregnancy in Africa was reported to be 25.2% [2]. In Ghana, Otu-Nyarko et al reported a prevalence of emotional abuse among cases in a case-control study to be 88.9% which is higher than that reported in this study [19]. Emotional/psychological abuse was the most common type of abuse reported by Jatta et al in Gambia [30]. It can therefore be suggested that, within the African context, emotional/psychological violence is among the most common types of IPV. Community norms towards IPV, the acceptance of violence as a way of life by some women, lower female empowerment and polygamy could all contribute to this trend of psychological violence in these African countries [11, 31].

The participants’ employment status was one of the factors associated with IPV in this study. Being employed [AOR = 0.16 (95% CI: 0.05–0.47), p = 0.001] was protective from experiencing IPV. Out of the 269 participants, 76.9% were employed, which was less than their partners’ employment rates of 97.4%. For these pregnant women in the Ledzokuku Municipality, although the majority of the participants were in employment, efforts to promote gender equality through economic empowerment projects are still necessary. The findings of this current study corroborate the study of Field et al in South Africa who reported a positive association between IPV and the employment status of women, with pregnant women more likely to experience IPV if they were unemployed [16]. Men who commit violent acts take advantage of the fact that many African women are economically vulnerable and depend on their spouses for financial support and access to prenatal care [16, 32].

Several studies have reported a positive association between the alcohol-consuming habit of partners of pregnant women and the experience of IPV [5, 16, 19, 28, 29]. These findings corroborate the current study where pregnant women whose partners used alcohol had 10 times the odds of experiencing IPV compared to women whose partners didn’t use alcohol. Findings from this study support the systematic review and meta-analysis by Alebel et al. [33] and Bifftu and Guracho [34] in which pregnant women whose partners used alcohol were 11.4 times and 2 times, respectively, more likely to be abused when compared to their counterparts.

The strong association between alcohol use by partners and IPV could be because alcohol intake has a direct impact on consumers’ cognitive and physical functions. This mental distortion may result in aggressive behaviours in the relationship and a rise in violent incidents [29, 35]. Alcohol use may also heighten a partner’s sense of power and authority, enabling him or her to exert control over women [29]. From this current study, the alcohol-drinking habit of pregnant women was also a significant predictive factor of IPV and 5.6% of participants reported drinking alcohol. Contrary to these findings, Chasweka et al in Malawi found no association between alcohol consumption by pregnant women and IPV [36] in a study that employed a cross-sectional quantitative method among pregnant women attending an antenatal clinic in a District Hospital. The reason for no reported association between alcohol consumption by pregnant women and IPV could be due to the very low alcohol consumption rate of 0.7% among the study participants [36].

Studies have reported a statistically significant positive association between previous IPV exposure and IPV exposure during pregnancy [37, 38]. Among the victim-related factors associated with IPV from a systematic review and meta-analysis were the history of childhood violence and a family history of violence [34]. Pregnant women who had a history of childhood violence and a family history of violence were 3.14 times and 1.68 times respectively, more likely to experience IPV, [34] which was comparable to the findings of this current study. Luhumyo et al in Kenya [38] and Clarke et al in Uganda [37] found a significant association between IPV and a previous experience of IPV. IPV was more likely to occur during pregnancy in women who had previously experienced it [37]. Luhumyo et al reported a significant association between IPV and a previous experience of IPV such that having previously experienced IPV was linked to a 17 times greater risk of physical/sexual IPV compared to not having previously experienced IPV [38]. This was also a facility-based cross-sectional study but within a teaching and referral hospital. The social learning theory of IPV states that prior exposure to IPV is a background component that plays a role in the development and maintenance of aggression, which in turn causes IPV to occur during pregnancy [38].

Conclusion

The findings of this study have illustrated a high prevalence (11.2%) of IPV among pregnant women attending a primary antenatal care clinic in a resource-limited setting. Healthcare providers in primary care such as family physicians, obstetricians, midwives, medical officers, and community health nurses need to recognize IPV as a medical condition that can occur in pregnancy and be ready to assist and manage the victims when it is detected. There is a need for policies by health service managers and opportunities to train healthcare workers in primary care to identify IPV. The implications of the association between the significant factors (ie. employment status, alcohol use by women or partners and previous history of violence) and IPV in clinical practice are that healthcare providers must be aware of the true impact of IPV to aid the development of successful IPV preventive strategies through screening during pregnancy. The findings from this study suggest that, in order to facilitate timely interventions, primary care antenatal clinics should incorporate targeted screening for IPV among pregnant women to provide opportunities to address this issue in primary care settings.

Supporting information

Acknowledgments

The authors are grateful to Anita Obeng and Patience Adotey who were midwives at the Antenatal clinic for assisting with data collection, entry, and clean-up. We also acknowledge the midwife in charge of the Antenatal clinic and the management of the Hospital. We are also grateful to all the pregnant women who consented to be part of the study.