How does intimate partner violence influence reproductive health?

Friday, March 10, 2017

Key finding: 25.8% of abortion clients had experienced recent intimate partner violence.

Research has shown for some time that physical or sexual violence perpetrated by a woman’s husband or sexual partner leads to poor reproductive health outcomes. But two recent Ipas-led studies conducted in Bangladesh shed light on some specific questions: What influence does intimate partner violence have on reproductive outcomes among women seeking abortion and on women’s decision-making about postabortion contraception?

Both studies are based on data collected from almost 500 women seeking abortion care at Bangladesh health facilities in 2013. One of the studies, published in the International Journal of Gynecology & Obstetrics, found that a large proportion of the women—25.8 percent—had experienced intimate partner violence during the preceding year. Those women were more likely to report that:

  • Contraception was difficult to obtain
  • Contraception was inconvenient to use
  • Their husbands/partners and in-laws wanted the terminated pregnancy more than they did
  • They did not want more children, but felt that their husbands/partners did
  • Their in-laws were opposed to contraceptive use
  • Their religion prohibits contraceptive use

The study also found that those women were more likely to:

  • Have had a previous induced abortion
  • Arrive at the health facility for the abortion alone
  • Receive postabortion care after an illegal induced abortion attempt
  • Undergo a medication abortion

“These findings suggest that abortion clients face multiple threats to their reproductive autonomy—from husbands, in-laws, and religious communities, not just from intimate partner violence itself,” says Erin Pearson, Ipas senior researcher.

The findings, she says, also give insight into strategies women may use to regain their reproductive autonomy through abortion: “Seeking abortion unaccompanied or using medication abortion, possibly to simulate miscarriage, may be strategies that women use to access abortion covertly in the presence of intimate partner violence.”

The Bangladesh context

Women seeking induced abortions in Bangladesh are a key population for understanding intimate partner violence and its influence on reproductive health. An estimated 50 to 60 percent of Bangladeshi women are affected by intimate partner violence during their lifetimes, compared to the global average of 30 percent.

And while induced abortion is illegal in Bangladesh except to save a woman’s life, menstrual regulation is a legal and widely available uterine evacuation procedure to establish non-pregnancy up to 10 weeks from a woman’s last menstrual period. Postabortion care is also widely available in Bangladesh, as is contraception.

“In this context,” Pearson says, “it’s striking that women who have experienced intimate partner violence are more likely to need postabortion care after an illegal and possibly unsafe abortion, rather than to access legal, widely available menstrual regulation services. It suggests that they could be facing pressure for childbearing and are seeking covert ways to terminate their pregnancies.”

Violence also linked to women’s decision-making on postabortion contraception

A second study, also led by Pearson, was drawn from the same data and focused on 398 women who had chosen pills, condoms, injectables or no contraceptive method immediately following the abortion procedure. It looked at their contraceptive use at four months postabortion and analyzed related contextual factors such as contraceptive history, fertility intentions and whether a woman had experienced intimate partner violence in the previous year.

This study, published in the journal Contraception, also found a substantial relationship to intimate partner violence. Contraceptive use among the entire group of women at four months postabortion was high (85.4 percent). Women who reported intimate partner violence, however, were much more likely (36.8 percent vs 19.5 percent) to have delayed the use of postabortion contraception, particularly if their husband had accompanied them to the abortion procedure.

Screening for violence and other recommendations

Referring to the findings of both studies, Pearson says, “Violence is a common thread.” Each study, therefore, offers recommendations for addressing the negative impact of intimate partner violence on women’s reproductive health outcomes.

The postabortion contraception study recommends that women be offered comprehensive, confidential counseling that includes:

  • violence screening
  • support for contraception initiation
  • an offer of “woman-controlled” contraceptive methods such as injectables or IUDs

Addressing reproductive coercion in health settings

The intimate partner violence study notes that women who had experienced violence could be faced with constraints on their reproductive autonomy not only from their husbands or partners, but from their in-laws or their religious communities. In light of that, the authors say interventions are needed not only in health facilities at the time of abortion, but also at the household and community levels to improve women’s reproductive autonomy. 

ARCHES (Addressing Reproductive Coercion in HEalth Settings) is a clinic-based harm reduction intervention that empowers women to implement strategies that mitigate the impact of reproductive coercion on their reproductive health. ARCHES has been shown to reduce reproductive coercion among family planning clients in the United States, but it has not previously been used in Asia or specifically with MR/PAC clients. This ongoing study seeks to adapt the ARCHES intervention for use with MR/PAC clients in Bangladesh and to test its effectiveness through a cluster randomized controlled trial. Overall, this study is expected to result in 1) evidence of the effectiveness of the adapted ARCHES intervention in increasing contraceptive use and reducing reproductive coercion, and ultimately in reducing the risk for future unintended pregnancy and unsafe abortion, and 2) evidence on the elements required for successful implementation in high volume MR/PAC clinics.

Such studies and interventions could ultimately improve gender equality not only in Bangladesh but in other settings where women face constraints on their freedom in making reproductive health choices.