This is the third part of a IH Blog series featured this summer, Intimate Partner Violence: Global Burden, Risk Factors and Outcomes.
Written by: Erica Hartmann MPH, MMS (c) and Dr. Heather de Vries McClintock PhD MSPH MSW
Intimate partner violence (IPV) is defined by the Center for Disease Control (CDC) as physical violence, sexual violence, stalking and psychological (or emotional) aggression by a current or former intimate partner (Violence Prevention, 2017). Consequences of intimate partner violence (IPV) can be immediate, long lasting, and invisible. The physical impact of IPV includes broken bones, lost teeth, hearing damage, and vocal cord damage due to attempted strangulation (Garcia-Moreno C et al., 2005). The World Health Organization’s multi-country study showed that women who were ever abused by their partner were twice as likely to report poor health and physical and mental problems when compared to women who were never abused (Garcia-Moreno C et al., 2005). Diagnoses resulting from IPV include irritable bowel syndrome, fibromyalgia, chronic pain syndromes, and asthma exacerbation (Crofford, 2007; Heise,Garcia Moreno, 2002). Additionally, violence during pregnancy is associated with miscarriage, late entry into prenatal care, stillbirth, premature labor, fetal injury, and low birthweight (Bailey, 2010; Garcia-Moreno C et al., 2005; Silverman, Decker, Reed, and Raj, 2006). IPV can have lasting, and often unseen consequences.
Intimate partner violence can be harmful to the victim and to the children in the home where violence is occuring. Studies from around the globe find that IPV is a leading predictor of child maltreatment (Hunter, et al., 2000; Family Violence Prevention Fund, 2006). Growing up in a home where the mother experienced violence is considered an adverse childhood experience, and is associated with greater likelihood of poor outcomes in later life such as alcoholism, drug abuse, and suicide attempts (Felitti, 1998).
Intimate partner violence (IPV) has previously been linked with child mortality in countries including Bangladesh, the United States, India, Malawi, and Timor Leste (Hossain, Sumi, Haque, Bari, 2014; Mwale, 2004; Silverman et al., 2011; Taft, Powell, and Watson, 2015; Garoma, Fantahun,and Worku, 2012). A recent study using data from the Timor Leste’s 2013 Demographic Health Survey (DHS) showed that women who experienced physical violence were 30% more likely to experience child loss (the death of one or more children), and women who experienced combined forms of violence were 45% more likely to experience child loss when compared with women who had not experienced violence (Taft, Powell, and Watson, 2015).
We sought to uncover the relationship between intimate partner violence and child loss using the Togo demographic health survey (DHS) administered between 2013-2014. In addition, we investigated the effect of emotional violence which to our knowledge, has not been investigated in associated with child loss. The Demographic Health survey is a nationally representative household survey that is administered by the United States Agency for International Development (USAID). This survey provides a wide range of monitoring and impact evaluation indicators and is developed in collaboration with the surveyed country. The Togo 2013-2014 DHS survey was translated into 13 languages and was administered by 90 highly trained individuals after gaining privacy and consent of the participant. The DHS survey assessed lifetime victimization of physical, emotional, and sexual violence (yes/no), and child loss (difference between the number of childbirths and number of living children, 1 or more coded as yes/ 0 coded as no). Covariates assessed included age, education, marital status, wealth index, employment, justification of wife-beating, and urban/rural residence. Data were weighted and analyzed through a bivariate logistic regression adjusting for covariates using SPSS version 14.
In total, 4842 Togolese women completed the domestic violence module of the Demographic health survey. In all, 36.5% of women reported victimization of physical, sexual, or emotional IPV in their lifetime. Women who experienced any form of IPV were 1.415 times as likely to experience child loss when compared to women who never experienced IPV (adjusted odds ratio (AOR) =1.415, 95% confidence interval (CI)=1.227,1.633). Women were significantly more likely to experience child loss if they experienced physical IPV (AOR=1.340, 95% CI = 1.135,1.582), sexual IPV (AOR=1.488, 95% CI = 162,1.905) or emotional IPV (AOR= 1.325, 95% CI = 1.143,1.536). Women who experienced combined forms of violence were at significantly increased odds of experiencing a child’s death when compared to women who never experienced violence (AOR=1.479, (95%CI = 1.231,1.778). We saw a significant association between all forms of intimate partner violence and child loss among this population of Togolese women. This finding indicates a need for child mortality interventions that address intimate partner violence to reduce Togo’s child mortality rate.
Addressing IPV requires strategies implemented at the individual, community, and policy levels. Screening for intimate partner violence during prenatal visits and providing social worker counseling to future mothers reduces recurrent episodes of IPV and improves childbirth outcomes (leading to higher birth weights and fewer premature births) (Kiely, Elmohandes, El-khorazaty, & Gantz, 2011). Data also indicates that policies including support programs for survivors such as shelters, housing programs, legal services, have been effective in reducing negative outcomes. The World Health Organization outlines strategies through which policy can most effectively reduce the burden of IPV suggesting that the healthcare and other sectors should have minimum standards for addressing this issue. These standards include establishing clear working protocols encompassing clear referral pathways for survivors of IPV (WHO Response to IPV, 2016). The degree to and nature in which countries follow these recommendations varies dramatically with some countries aggressively attempting to address the issue while others failing to even acknowledge its existence. The consequences of IPV are vast and impact people all over the world. Public health professionals are at the forefront of tackling this issue and will continue to play a critical role in reducing the global burden of IPV.
Please stay tuned for Part IV in this series: Interventions and Strategies for Addressing Global Intimate Partner Violence.
Erica Hartmann, MMS (c), MMS (c) 2020 is a student at Arcadia University who hopes to prevent violence by serving as a physician assistant specializing in primary care in communities with limited access to healthcare. Erica worked under Dr. Heather McClintock to uncover links between IPV and child loss in Togo, and hopes to continue researching global violence prevention interventions after graduating from Arcadia.
Dr. Heather F. de Vries McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life and Integrating Management for Depression and Type 2 Diabetes Mellitus Studies.
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