Prevalence and Correlates of Intimate Partner Sexual Violence Among Pregnant Women in Lamwo District - Northern Uganda

Introduction

Violence against women and girls (VAWG) is considered to be one of the most prominent human rights violations affecting 27% of women aged 15-49 years in their lifetime globally.¹ Violence against women gained more global recognition as a women’s rights violation since the advent of the COVID-19 pandemic following which it was declared to be a shadow pandemic with the most prevalent form of VAWG being intimate partner violence.^2,3 Intimate partner violence has been explicitly associated with not only health consequences of gynaecological and psychological nature among women but also contributes to 10% of all violent deaths, and it is associated with up to 290,000 years of potential life lost by its victims.⁴

The World Health Organization defines intimate partner sexual violence as “attempts to force a partner to engage in a sex-act of any kind, actual forceful engagement in a penetrative sex act, denial of a partner to use measures that can protect them from sexually transmitted infections during intercourse, denial to use contraceptive services, and forced abortion.’’⁵ In addressing concerns around IPSV, sustainable development goal five (SDG 5) target two seeks “to eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking, sexual and other types of exploitation.” Several studies have reported intimate partner sexual violence (IPSV) in pregnancy to include attempted and actual forced penetrative sex-acts and denial to use infection control measures, all of which have negative consequences, including emotional distress among pregnant women.^6,7,8 A South African, cross-sectional study that investigated the effect of IPSV on pregnancy outcomes by Covender et al. reported that among adolescent mothers, IPSV victims suffer from Post-Traumatic Stress Disorder (PTSD), somatic symptoms, and suicidal ideation which leads to higher incidences of antepartum depression, during which cortisol production significantly increases during pregnancy, subsequently affecting foetal growth.⁹ This had implications on foetal outcomes. Also, rape during pregnancy has been associated with urinary tract infections such as candidiasis and bacterial vaginosis. This leads to poor pregnancy outcomes such as spontaneous abortion, preterm labour chorioamnionitis, and postpartum complications. Intimate partner sexual violence not only affects the pregnant woman but also has tremendous effects on the foetus and neonates. It is linked to many negative outcomes, including preterm birth, premature rapture of membranes (PROM), and neonatal ICU admission.¹⁰ Current evidence suggests that there are significant increments in the risk of perinatal death among women exposed to IPSV.^11,12,13

However, despite these global efforts to eliminate IPSV, it is still the highest contributor to gender based violence with a 40% prevalence among married women according to Uganda Demographic Health Survey 2022, surpassing the rest of the world by 10%.¹⁴

In Lamwo district, Northern Uganda, IPSV has a prevalence of 59.9%, characterized by women experiencing emotional, physical, or sexual violence from a spouse. Even with such figures reported, it is noted that 51% of such cases go unreported partly due to the tolerance or acceptance of violence that is rooted in socio-cultural beliefs that men are unconditionally entitled to sex, bureaucratic systems, and delays amongst others.¹⁴ There is relatively limited documentation of IPSV among women during pregnancy in Lamwo District. This study, therefore, sought to assess the prevalence and correlates of intimate partner sexual violence during pregnancy among pregnant women in Lamwo district, Northern Uganda to generate evidence that will inform the implementation of policies to improve maternal health outcomes.

Methods

Results

Key socio-demographics information including age, education, marital status, duration in marital, religious denomination, and employment status for the women from the study among pregnant women in Lamwo district, Northern Uganda is presented in Table 1. Most respondents fell between the ages of 18 and 24 (59.2%) followed by the second largest age group, 25-31years (31.9%). More than three-quarters were cohabiting (76.9%), and nearly two-thirds had been in a marital relationship for less than five years (65.8%). Many of the pregnant women were Catholic (59.2%), followed by Christian (Pentecostal) (29.2%). More than four-fifths were formally educated (86.5%) of which the majority had primary education as highest achievement (65.8%). More than four-fifths were not currently employed (90.8%).

The study findings show a quarter, 24% (n=63), of the pregnant women had experienced intimate partner sexual violence of various forms during their current pregnancies in Lamwo district, Northern Uganda. Table 2 presents the forms of IPSV experienced and their magnitude. More than four-fifths of the pregnant women interviewed had not experienced spouse/intimate partner coercion or unwanted sexual advances since conception of the current pregnancy (90.8%), spousal denial to use measures that can protect pregnant wife from sexually transmitted infections during intercourse (81.5%), and 86.2% had not experienced forceful sexual intercourse. Half of the pregnant women who had been forced to have sex during pregnancy reported it had been on one occasion (50.0%).

Disaggregation of the forms of IPSV by level of incidence among the pregnant women are presented in Table 3. The majority (73.0%) had been denied using measures that can protect pregnant woman from sexually transmitted infections, during intercourse, with the second most prevalent form being forceful sexual intercourse (52.4%).

The bivariate analysis findings of the relationship between individual characteristics and IPSV showed that pregnant women who were carrying their third pregnancy (cPR = 5.211) and first pregnancy (cPR = 5.162) were more likely to experience IPSV 5 times higher than those carrying their second pregnancy (cPR = 4.433). The prevalence of IPSV during pregnancy was nearly five times as high among pregnant women who had ever experienced any intimate partner sexual violence in any of their previous pregnancies (cPR = 4.977) compared to those who had never experienced that violence. The prevalence of IPSV was less by 49% among pregnant women who rated the level of communication with their spouse as being high (cPR = 0.517) compared to those who rated it as being low (Table 4).

The relationship between interpersonal characteristics and IPSV showed six variables were statistically significant: women whose spouses allowed them to talk with neighbours or visit friends were more likely to experience IPSV during pregnancy 14 times (cPR = 14.038) as compared to women whose spouse consequences” (cPR = 0.316), and “whose spouses had a habit of engaging in fights (cPR = 3.176), women whose spouses had a preference for particular gender of children (cPR = 2.096), and those whose partners had ever physically abused them (cPR = 1.703). The least factor to influence sexual violence was “spouses allowed them to go somewhere at own accord, without consequences” (cPR = 0.316), and “whose spouses used alcohol” (cPR = 0.308).

The results of logistic regression modelling exploring the 10 indicators significant at the bivariate level, only the level of communication with spouse was insignificant after adjustment for confounders at multivariate level (Table 4). The prevalence of IPSV during pregnancy was 12 times higher among women whose spouses allowed them to talk with neighbours or visit friends (aPR = 12.554) compared to pregnant women not permitted. The findings show that pregnant women who were carrying their first pregnancy (aPR = 4.844) and second pregnancy (aPR = 4.696) were four times more likely to experience IPSV during pregnancy. However, women who were carrying their third pregnancy had an IPSV prevalence five times higher (aPR 5.307) compared to those who had carried more than three pregnancies at the time. This was followed by pregnant women who had ever experienced any intimate partner sexual violence in any of their previous pregnancies (aPR = 4.889), spouse had a habit of engaging in fights (aPR = 4.043), whose spouses had ever physically abused them (aPR = 1.838), and women whose spouses preferred a specific gender of children (aPR = 1.684). The women whose spouses used alcohol (aPR = 0.308) and spouses allowed them to go somewhere at own accord, without consequences (aPR = 0.394), were the least likely to be associated with sexual violence during pregnancy. Finally study findings revealed that indicators of gravidity (1-3): ever experienced any spouse sexual violence during pregnancy, spouse has a habit of engaging in fights, substance used if non-illicit (alcohol), and spouse ever physically abused wife were significantly associated with sexual violence among pregnant women (Table 4).

Discussion

The prevalence of IPSV in the study was 24%, among pregnant women with 73% of them being denied by their spouses from using measures to protect them from sexually transmitted infections. This finding indicates the persistent IPSV trend in the general population of the country. This may be due to unrelenting practices from cultures, and traditions of some subregions in Uganda where male dominance is highly prevalent even in the in the context of conjugal rights.¹⁷

This prevalence is slightly higher than the national prevalence of 22%.¹⁸ This could be due to the fact that Uganda ratified the Convention on the Elimination of All Forms of Discrimination Against Women and Uganda’s Constitution accords women full and equal dignity of the person with men and prohibits any vice that undermines their welfare, dignity, or status.¹⁹ These legal provisions likely foster a socio-legal environment in which women are less vulnerable to the factors that typically drive IPSV. However, a study done reported a higher prevalence at 27.8% in Eastern Uganda and 36.1% in Western Uganda.²⁰

Similarly, prevalence of 24% is lower compared to the recent meta-analysis findings which indicated that Northern Uganda a region from which Lamwo district belong has one of the unacceptably highest prevalence of IPSV (70.3%) in SSA and 30% in East Africa.²¹ The low prevalence could be due to lax in restrictive gender norms (such as women subordinate, bride payment and justified violence)²², improved household economic security and adequate institutional responses in a predominantly patriarchal society. Likewise, talking sexual experience could be less sensitive in Lamwo. Therefore, the chances of disclosing if they are experiencing some form of sexual violence from their intimate partners is likely to be high. particularly with a supportive, confidential, and respectful process.

The prevalence of this study is comparable to the studies done in Bangladesh (26.3%)²³ and South Africa (26%).²⁴ Also, results are consistent with findings in Ghana and Ethiopia at 24.4%.^25,26 The similarity in prevalence across diverse cultural, geographical, and socioeconomic contexts suggests that IPSV is a global public health concern during pregnancy, not an isolated phenomenon.

The IPSV prevalence of 24% in this study is lower than in several studies in Nigeria (34.6%)²⁷and Kenya (34.8%).²⁸ In contrast, the findings were higher than the prevalence of IPSV globally at 14%, in Tanzanian (15.4%), Ethiopia (18.6%), Bangladesh (18.5%), Vietnam (10%). and Ghana (3.3%).^29-34 This could be attributed to high levels of awareness and sensitization of men in those settings, which calls for more intervention on IPSV in the study area.

Overall, the difference in IPV prevalence during pregnancy between the current study and some other studies included women who were less than 24 weeks gestation or beyond 20 weeks gestation,^34,35 yet the current study included pregnant women in all trimesters.³³ It is therefore possible that there was some under estimation of IPV following the exclusion of some pregnant women in the first and early second trimesters. Secondly, there were also fundamental methodological differences between the studies.

In this study, the second most prevalent form of IPV was forceful sexual intercourse at 52.4%. This is higher than the Indian study at 30.7%.³⁷ This could be linked to the past civil wars that were characterised by the violation of human rights, including sexual violence against women.³⁸ The forceful sex puts women at risk of STIs including HIV infection, vaginal tract trauma, and obstetric complications.^39-41 This calls for policy change and action towards women empowerment through education and skill development.

The findings show that primigravida women were more likely to experience IPSV during pregnancy, and the lesser the parity the more likely for a woman to experience IPSV from their partners. This could be attributed to the effect of pregnancy on sexual drive which varies across gravidities and parities.^42-44 A survey reported that women of lower parity and gravidity are more likely to experience low sex drive and sexual dysfunction during pregnancy.¹⁴ As such, they tend to be more resistant to demands for intercourse by the spouse during pregnancy. This may be perceived as disrespect by a man in a patriarchal society such as Lamwo, which can subsequently lead to marital rape in a bid to show authority and dominance.

Similarly, several studies have reported the odds of experiencing IPSV was significant among pregnant women whose spouses had a habit of engaging in fights and had ever physically abused them.^45-47 This could be that men who are fond of physical abuse are also more likely to be embracers of patriarchy, and hence, more likely to demonstrate male dominance whenever their masculine positions are threatened, for instance, when their wives deny them intercourse even when pregnant.

Also, this study is consistent with several studies of women whose spouses preferred a specific gender of children were more likely to experience IPSV in this study.^48,49 In most cases, the futile attempts to have a particular gender of the child particularly sons over daughters by a man may aggravate the assertiveness of a pregnant woman’s consistent preference of a particular gender causing conflict. Subsequently, this bolsters a propensity of the man to sexually violate the wife.

Additionally, a similar study established that IPSV was more prevalent among women who had their first or third and subsequent pregnancies and not their second pregnancies.²¹ This could be because of various new stressors and uncertainties, unmet relational expectations during their first pregnancies while in the third and subsequent pregnancies the increased pressure of unmet needs, increased stress, financial strain and change in relation dynamics could predispose to more IPSV than the second pregnancy. The lower prevalence of IPSV in the second pregnancy would mean a period of transition and adjustment with stronger social support network for women, increased pressure of family expansion, and more partner support. Also, different gravidities experience varying levels of marriage dissatisfaction which might lead to violence.

This study has both strengths and limitations. The strength of this study can be attributed to WHO and CDC indicators used to assess IPSV during pregnancy. This yielded valid responses for the outcome variables, thus, producing a more reliable and unbiased assessment. However, it cannot be entirely ruled out that there was no concealment of IPSV, like missed marital rape that may have affected the magnitude of the outcome obtained. Also, the study was confined to female participants only. Yet, IPSV is not a gender specific problem as the experiences of men also have significant implications for health service delivery.

Conclusion

Intimate partner sexual violence is prevalent among pregnant women in Lamwo district. Out of every 10 pregnant women, two of them are sexually violated with the most common form of intimate partner sexual violence among them being denial to use measures used to protect her from sexually transmitted infections. The implication is to understand how the IPSV factors correlate with IPSV. Findings indicate gravidity, habit of engaging in fights by the spouse, having ever been physically abused by spouse, and spousal preference for a gender of children correlate more with IPSV. By pinpointing these psychosocial and demographic correlates, the data can already inform targeted public-health strategies, such as community-based screening for IPV in antenatal clinics and tailored counselling for couples with a history of physical or verbal aggression in Lamwo district and other similar settings. Further research is needed, particularly qualitative approaches with the ability to gain insight into the perceptions of victims and perpetrators of intimate partner sexual violence.

Conflict of interest

The authors report that they have no competing interests.

Overall Contribution

All authors declare overall contribution to the study in project design, data collection, analysis and manuscript writing. Each author reviewed and accepted the final copy and certifies to be responsible to all details of the work.