Intimate partner violence (IPV) around the time of pregnancy is a serious public health concern and is known to have an adverse effect on perinatal mental health. In order to craft appropriate and effective interventions, it is important to understand how the association between IPV and postpartum depression (PPD) may differ as a function of the type and timing of IPV victimization. Here we evaluate the influence of physical, sexual and psychological IPV before, during and after pregnancy on PPD.Cross-sectional survey data was collected between October 2015 and January 2016 in the Chandpur District of Bangladesh from 426 new mothers, aged 15–49 years, who were in the first six months postpartum. Multivariate logistic regression models were used to estimate the association between IPV and PPD, adjusted for socio-demographic, reproductive and psychosocial confounding factors.Approximately 35.2% of women experienced PPD within the first six months following childbirth. Controlling for confounders, the odds of PPD was significantly greater among women who reported exposure to physical , sexual  or psychological  IPV during pregnancy as opposed to those who did not. However, both before and after pregnancy, only physical IPV evidences a direct effect on PPD. Results highlight the mental health consequences of IPV for women of Bangladesh, as well as the influence of timing and type of IPV on PPD outcomes.The findings confirm that exposure to IPV significantly increases the odds of PPD. The association is particularly strong for physical IPV during all periods and psychological IPV during pregnancy. Results reinforce the need to conduct routine screening during pregnancy to identify women with a history of IPV who may at risk for PPD and to offer them necessary support. Culturally, pregnancy is often viewed as a time of happiness and expectancy in women’s lives, with the welcoming of the next generation and growing anticipation of the joys a new child will bring to the family. At the same time, pregnancy can also be a stressful and anxiety-provoking life event , and manPPD has been recognized as a significant global public health concern due to its profound health consequences for both mothers and their families , 11. PPDIPV includes acts of physical, sexual and psychological coercion along with controlling behaviors against women by a current or former intimate partner , 31. OneAlthough our understanding regarding the links between IPV and PPD is progressing, notable gaps remain. Until recently the majority of research has focussed primarily on physical IPV , 48, andWhilst the literature on IPV in Southeast Asia is growing, it still remains limited and there are few scholarships examining the association between IPV and PPD for women of Bangladesh. To help build this important knowledge base, we assess how the association between IPV and PPD changes as a function of the type and timing of IPV in a population-based sample of new mothers in Bangladesh. The aim of this study is to examine whether:1) recent exposure (occurred after childbirth) to physical, psychological and sexual IPV is associated with PPD in the first six months after childbirth; and 2) prior exposure (occurred before and during pregnancy) to physical, psychological and sexual IPV is also associated with PPD. Understanding the association between PPD outcomes and exposure to different forms of IPV during different periods has clinical implications regarding early detection and targeted preventative measures around the time of pregnancy to support at-risk women.A cross-sectional survey was conducted from October 2015 to January 2016 in two sub-districts of the Chandpur district of Bangladesh. New mothers who visited vaccination centers to receive their baby’s vaccinations were the target population. Married women between 15–49 years of age currently living with their husbands for the last two years, and who had at least one child aged six months or younger were eligible for the study. These criteria were used to determine the women’s experience of IPV from their current husband. A multistage random sampling method was adopted to identify vaccination centers from which to draw 426 estimated subjects. Interviewers approached 453 postpartum mothers to reach the desired sample size, yielding a response rate of 94%.The data collection procedure has been described in detail previously in , 51. FacParticipation was entirely voluntary and confidential and did not affect receiving health care in any way. Women who reported an experience of IPV were offered primary counselling services and referrals to local social and psychological services. Women who scored ≥10 on the EPDS were referred to the nearby district hospital for adequate follow-up . The intEthical approval was received for scientific and ethical integrity from the National research ethics committee of Bangladesh Medical Research Council (BMRC/NREC/2013-2016/305) and Griffith University Human Research Ethics Committee (CCJ/41/14/HREC) before conducting the study. The study was also conducted following the WHO guidelines on ethical issues for violence research . InterviThe main outcome of the present study was postpartum depression assessed by using the Bangla version of the Edinburgh Postpartum Depression Scale (EPDS) . The EPDEach participant was asked if she had experienced any of these symptoms during pregnancy or before, referred to herein as previous depressive symptoms (categorized as: no = 0 and yes = 1).Women’s experience of IPV before, during and after pregnancy was the main research interest, and for the purpose of the study ‘intimate partner’ refers to the respondent’s current spouse. The study collected information on IPV experienced by women before, during and after pregnancy using the domestic violence module from the WHO’s Demographic Health Survey Questionnaire. The domestic violence module used in the WHO study was validated for use in Bangladesh and some other countries . A positA woman was coded as having experienced sexual violence by an intimate partner if she reported having been physically forced to have sexual intercourse; having intercourse out of fear, or being forced to perform other sexual acts that she found degrading or humiliating. Psychological IPV was measured by at least one affirmative response to questions asking whether or not the respondent’s husband had insulted her or made her feel bad about herself; humiliated her in front of others; threatened to hurt her or someone close to her; isolated her from friends and family; denied her access to money or other basic resources; or threatened to divorce her. The Cronbach’s alphas for physical, sexual and psychological IPV scale in this study were 0.78, 0.47 and 0.75, respectively.Each participant was asked if she had experienced any of these indicators of IPV during the first six months after birth of her last baby, during her pregnancy, and during the 12 months prior to pregnancy, referred to herein as ‘IPV after pregnancy’, ‘IPV during pregnancy’ and ‘IPV before pregnancy’, respectively. Physical, sexual and psychological IPV before, during and after pregnancy were coded as no (= 0) and yes (= 1).Several socio-demographic variables that have been theoretically and empirically associated with IPV and PPD , 57–62 wObstetric and reproductive characteristics such as pregnancy intention , parity , number of children under five years of age , complications during childbirth , mode of birth , a husband’s preference for a son  and timing of breastfeeding initiation  were taken into consideration. Regarding psycho-socio-cultural characteristics, to ascertain the relationship with their mother-in-law, women were asked to evaluate their relationship with their mother-in-law providing a score from 1 to 9, where higher score indicates a more positive relationship  = 1, good (7–9 points) = 2).We control for social support given its protective impacts on mental health in general and PPD in particular , 50, 63.Stress can increase the odds of PPD , 67, so High self-esteem can also protect against PPD . To contWomen with more controlling husbands are at risk for both IPV and PPD, an influence we control with a scale comprised of the following items: (a) husband tries to keep her from seeing friends; (b) tries to restrict contact with her family of birth; (c) insists on knowing where she is at all times; (d) does not trust her with any money; (e) gets angry if she speaks to another man; (f) is often suspicious that she is unfaithful; and (g) expects her to ask permission before seeking health care for herself. The responses to these variables are dichotomous (0 = no and 1 = yes). Based on the total scores, women with scores in the bottom third percentile were classified as having husbands who were less controlling (= 0), those with scores in the middle third percentile as having moderately controlling husbands (= 1), and those in the top third as having husbands who were highly controlling (= 2). The controlling behaviors scale was validated for use in Bangladesh and some other countries . The CroWomen who experience a higher degree of autonomy are less likely to report IPV or PPD . We contSPSS version 22.0 for Windows  was used for coding and analyzing the data. We calculated descriptive statistics for mother’s postpartum depressive symptoms, and exposure to IPV as well as all of our control variables. Our analysis proceeded in two stages. First, we conducted a series of cross-tabulations to assess the bivariate relationships between PPD and the relevant covariates and controls and report chi-squares as our measure of significance. A two-tail p-value of <.05 was set to refer the level of statistical significance for all analyses. We then proceeded to a series of multivariate models that allow us to assess the strength of any association between IPV and PPD, controlling for a range of other known influences. These models employed multivariate logistic regression to estimate adjusted odds ratios (AOR) and 95% confidence intervals to compare the strength of the associations between each of the covariates and PPD. To assess the influence of IPV after childbirths on the odds of PPD, we ran four adjusted multivariate logistic regression models—one for each type of IPV after childbirth to assess the separate effects of different forms of IPV on PPD, and one full model for all types of IPV together with the control variables to examine the effects of each type of IPV, controlling for the other. Each model also included the control variables described above. A second set of adjusted multivariate logistic regression models examined the influence of IPV before and during pregnancy on PPD outcomes. Here we ran one model for all types of IPV victimization before pregnancy and another for all types of IPV victimization during pregnancy to examine whether past IPV victimization is associated with experiencing PPD. The multicollinearity of the variables was tested by auditing the variance inflation factors (VIFs), but there was no evidence that this was a problem (VIF’s<2.5).Approximately, a quarter of women (25.8%) had low decision-making autonomy and one-third of the women (29.6%) reported relationship difficulties with their mother-in-law. About, one in three (27.7%) women’s husband had high controlling behaviors and 26.8% of women reported a prior history of depressive symptoms. Approximately 57% of women had high perceived stress, 58.5% of women had low self-esteem and nearly one-third of the women (30%) had low social support.The prevalence of physical IPV during the 12 months before the pregnancy was 52.8%, while the comparative figure for during pregnancy and after childbirth was 35.2% and 32.2% respectively. The prevalence of psychological IPV before pregnancy was highest (67.4%) compared with that during pregnancy (65%) and after childbirth (60.8%). The rate of sexual IPV after childbirth was lower (15.5%) than that of before (21.1%) and during (18.5%) the pregnancy.Out of 426 participants, 150 had total EPDS scores of 10 or above, indicating the prevalence of PPD is 35.2%. We begin by describing the bivariate relationships between the forms and timing of IPV and PPD outcomes among new mothers. As expected, physical, sexual, and psychological IPV both during pregnancy and after childbirth were significantly associated with PPD among the women in this sample. When we examine IPV experiences prior to pregnancy, physical and psychological IPV increase the odds of PPD, but that is not the case for sexual IPV. Overall, 73.7% of women who experienced physical IPV, 56.1% of those experiencing sexual IPV and 52.9% of women experiencing psychological IPV after childbirth also reported PPD. Similarly, during pregnancy, approximately two-thirds of women who experienced physical IPV (66.7%) and sexual IPV (63.3%) and nearly half of the women (52.7%) who experienced psychological IPV also reported PPD. Prior to pregnancy, the corresponding figures were 60.4%, 41.1% and 49.4%, respectively who reported PPD. Moreover, approximately 57.4%, 79.2% and 71.8% of women who experienced all types of IPV before, during and after pregnancy respectively also reported PPD. Bivariate results see  also reiResults reported in As is evidenced in Similar to the influence of IPV victimization after childbirth, results reported in During pregnancy, the picture looks notably different. At this stage, physical, sexual and psychological IPV victimization were all found to be independent risk factors for experiencing PPD after adjusting for other control variables  highlighted that more research utilizing a longitudinal approach is warranted to examine how IPV victimization not only before and during pregnancy but also after childbirth may affect women’s mental health. Though our study is not longitudinal, it includes retrospective and time ordered measures of abuse, thus offering some insight into the longitudinal links between IPV and PPD. To our knowledge, this is the first study from South Asia, particularly from Bangladesh that specifically examined the association of IPV with postpartum depressive symptoms as a function of the type and timing of IPV occurrence. The strength of the study is the large sample size and the introduction of a large number of different socio-demographic, obstetric and reproductive, and psycho-socio-cultural factors. In addition, it is one of the few studies that included various types of IPV experienced at different time periods to explore the likelihood of experiencing PPD. Most importantly, by using internationally recognized scales and questionnaire for this study, the findings are internationally comparable. It is also important to acknowledge that the potential recall bias of the particular cohort of women in this study is greatly reduced because the mothers were surveyed within six months of the birth. Nevertheless, our findings should be interpreted while acknowledging several limitations to the study. Specifically, due to cross-sectional nature of this study, it is not possible to determine the exact temporal relationship between exposure to IPV and PPD. Neither, did we focus on the frequency of IPV over time. In addition, although we collected information on violence and depression before and during pregnancy and in the postpartum period, because the data are cross-sectional it is possible that women’s current depression and violence experiences influence their recollection of prior violence and depressive symptoms. However, regardless of the limitations, we do see changes in these experiences across the three periods, which would indicate that most women are able to disentangle their current state from previous ones and respond accordingly. It is also relevant that the data were collected from one district only, therefore, the findings may not be considered to be representative of the general population. Although a substantial number of predictors were adjusted in this study, some of the important variables were not controlled for, such as the health of the baby and difficult infant temperament. Finally, due to budget and time constraints, we were only able to collect data on exposure to IPV before, during and after pregnancy at a single period, instead of interviewing women at multiple periods. However, this study serves as a foundation for recommending future research on this important issue to explore how IPV victimization before, during and after pregnancy affects the health and well-being of the women of Bangladesh.The high prevalence rate of IPV and its association with postpartum depression reflect the importance of acknowledging both of them as a significant public health concern in Bangladesh. The strong association between IPV victimization around the time of pregnancy and the likelihood a mother will exhibit PPD symptoms reinforces the need to conduct routine screening during pregnancy to identify women with a history of IPV or those currently experiencing IPV who may at risk of developing PPD. This particular cohort of women likely evidence a variety of additional risk factors that further heighten their risks of PPD and could clearly benefit from a range of help and support offerings. In developing countries like Bangladesh, it is important that well-organised referral pathways and support mechanisms and organizations be put in place before a screening program commences . We propS1 File(SAV)Click here for additional data file.

Intimate partner violence (IPV) during pregnancy and postpartum is a serious global health problem affecting millions of women worldwide. This study sought to determine the prevalence of different forms of IPV during pregnancy and postpartum and associated factors among women in Dar es Salaam, Tanzania.We conducted a cross-sectional study among 500 women at one to nine months postpartum in three health facilities in the three districts of Dar es Salaam: Temeke, Kinondoni and Illala. Two trained research assistants administered the questionnaire, which aimed to examine sociodemographic characteristics and different forms of IPV.Of the 500 women who were interviewed, 18.8% experienced some physical and/or sexual violence during pregnancy. Forty-one women (9%) reported having experienced some physical and/or sexual violence at one to nine months postpartum. Physical and/or sexual IPV during pregnancy was associated with cohabiting  and having a partner who was 25 years old or younger . Postpartum, physical and/or sexual IPV was associated with having a partner who was 25 years old or younger .We found that IPV is more prevalent during pregnancy than during the postpartum phase. There is also continuity and maintenance of IPV during and after pregnancy. These results call for policy and interventions to be tailored for pregnant and postpartum women. Intimate partner violence (IPV) has been recognized as a highly prevalent and important public health problem affecting the wellbeing and health of millions of women and children worldwide. Globally, it has been estimated that one-third of women will experience some form of physical and/or sexual violence in their lifetime and that one in three homicides of women are committed by intimate partners , 2.Population-based studies across the world have found the prevalence of physical IPV during pregnancy to be between 1% and 28% . A systeThe adverse effects of IPV during pregnancy for both mothers and their children have been well documented –10. SeveWhile there is increasing evidence of the prevalence of physical and/or sexual violence in pre-and postnatal cases in sub-Saharan African countries, there is still limited data about the prevalence of different forms of pregnancy-related IPV and factors associated with IPV during and after pregnancy. This study aimed to determine the prevalence, nature and factors associated with IPV among pregnant and postpartum women in Tanzania.The study was conducted between December 2014 and March 2015 among women attending clinics for children under the age of 5  in three health centers in Dar es Salaam. The under-five clinics promote healthy behavior and family planning, as well as offering immunizations and extra care for low birthweight babies or babies born to HIV-positive mothers. The three health centers were intentionally selected from the Temeke, Illala and Kinondoni districts of Dar es Salaam because they offered relatively similar services and had a representative number of attendees (ranging from 50 to 200 children per day). The health center in Kinondoni mainly provided antenatal care and under-five clinics, while the other two health centers offered a wider range of services, including in-patient services.The mothers were recruited after their visits to the under-five clinic. All attending mothers aged 18 years and older who were physically fit and without cognitive impairment were invited to participate in the study. The response rate was 97%: 541 women were approached to take part in the study and only 18 declined to participate. We excluded 23 women from the study: 15 for security reasons (they attended the clinics with their partners and such partner presence could be intrusive and unsafe) and eight because they were not the biological mothers.We used a consecutive sampling technique to select study participants for the interviews. A research assistant explained the nature of the study to each woman in a separate private room, read the consent form and obtained her verbal consent. Due to the sensitive nature and cultural context of the study, we used a verbal consent since a written consent might have implied legal consequences.Two trained female research assistants with diplomas in nursing and midwifery administered the study questionnaires in Kiswahili, the most widely spoken language in Tanzania. The participants were not financially compensated, but refreshments were provided during the interviews. Women perceived to be in immediate danger were referred to gender-based violence intervention units, which were led by trained medical staff and social workers in the respective health centers.The study received ethical approval from the National Institute of Medical Research (NIMR) in Tanzania and from the University of Heidelberg. It was endorsed by regional medical officers and medical officers in charge in the respective hospitals. We observed a protocol regarding the protection of human subjects which adheres to the WHO ethical guidelines . ParticiThe structured questionnaire included information about the participants’ sociodemographic characteristics, such as age, education, employment status and marital status. The participants also provided information about their partner’s age, education and employment status, as well as the sex and age of the child.Intimate partner violence was captured through the instrument from the WHO multi-country study, which includes five forms of IPV . Women wPhysical violence (6 questions): Has your partner ever; slapped you or thrown something at you that could hurt you? Pushed you, shoved you or pulled your hair? Hit you with his fist or with something else that could hurt you? Kicked you, dragged you about or beaten you up? Attempted to choke you or burned you on purpose? Threatened to use or actually used a gun, knife or other weapon against you?Sexual violence (3 questions): Has your partner ever; ever forced you to have sexual intercourse by threatening you, holding you down or hurting you in some way? Did you ever agree to have intercourse when you did not want to because you were afraid of what your husband/ partner might do if you refused? Did your partner or any other partner ever force you to do something sexual  that you did not want to do?Psychological violence (4 questions): Has your partner ever; insulted you or made you feel bad about yourself? Belittled or humiliated you in front of other people? Done things to scare or intimidate you on purpose ? Threatened to hurt you or someone you care about?Controlling behavior (5 questions): Has your partner ever; tried to keep you from seeing your friends? Tried to restrict contact with your family of birth? Insisted on knowing where you are all times? Acted jealous and get angry if you speak with another man? Often been suspicious that you are unfaithful?Economic violence (two questions): Has your partner ever; taken your earnings or savings from you against your will? Refused to give you money for household expenses, even when he has money for other things?The scale has been validated and used in Tanzania .Data analysis was done using STATA version12. A woman was considered to have experienced IPV during and after pregnancy if she answered yes to any question within any of the five forms of IPV.Descriptive statistics included frequencies of each variable. The first step in the analysis was to screen all potential factors that could influence the dependent variable. Variables that showed a p-value of <0.3 in the univariate models were selected and used in the logistic regression model analysis, associated factors controlled each other. A p-value <0.05 was considered to be significant and an odds ratio <1 indicates the likelihood of reduced risk, while an odds ratio >1 could be considered an increased risk.We interviewed 500 women from the three selected under-five clinics in Dar es Salaam: 168 (33.6%) women in Kinondoni, 182 (36.4%) in Temeke and 150 (30%) in Illala. The mean age of participants was 27 years, ranging from 18 to 48 years; 116 women (23.2%) were aged 18–21 years, 332 (66.4%) were aged 22–35 years and 52 (10.4%) were aged 36 years or older. The majority of women  were married; the rest were cohabiting  or single . The lengths of their relationships ranged from 1 to 28 years. For more than half the women  among the participants, followed by secondary education and above . A large number of the participants were unemployed ; the rest were self-employed  or employed .The participants’ partners had a mean age of 32 years, ranging from 18 to 65 years. Of them, 98 (16.6%) were aged 18–25 years, 251 (50.2%) were aged 26–35 years and 151 (30.2%) were aged 36 years or older. The majority of partners  had a primary school education or below and the rest had secondary education and above. More than half of the partners were self-employed  and the rest were employed.Of the participants, 18.8% (n = 94) reported experiencing some form of physical and/or sexual IPV during the index pregnancy, 12.4% (n = 62) reported experiencing some act of physical violence in the index pregnancy and 9% (n = 45) reported experiencing some act of sexual violence. In addition, 31% (n = 155) reported experiencing psychological violence, 15% (n = 75) reported experiencing economic violence and 48.4% (n = 242) reported experiencing controlling behavior during their index pregnancy. Some form of psychological and/or controlling behavior was experienced by 58.2% (n = 291) of the participants.Women who were cohabiting were more likely to experience physical and/or sexual IPV in the index pregnancy compared to their single counterparts . If they had partners aged 25 years or younger, they were more likely to experience physical and/or sexual IPV during their index pregnancy than women with partners aged 26–35 years . Other factors were not significant .Married women were more likely to experience psychological violence in the index pregnancy than their single counterparts . Women who were cohabiting , single (AOR 8.2 CI 4.2–15.8) or who had a partner with a primary school education  were more likely to experience economic violence.There was also an overlap between different forms of IPV during pregnancy .Some participants reported IPV between one and nine months postpartum. 8.2% (n = 41) reported physical and/or sexual violence, 5.2% (n = 26) reported physical violence and 3.8% (n = 19) reported sexual violence. Psychological violence postpartum was reported by 17.8% (n = 89) of participants, economic violence by 11.4% (n = 57) and controlling behavior by 44.4% (n = 222).In addition, some participants only experienced violence postpartum and not during pregnancy. Of all the participants, 5% (n = 25) experienced psychological IPV, 2.6% (n = 13) experienced physical IPV, 1.6% (n = 8) experienced sexual IPV, 2.6% (n = 13) experienced economic IPV and 4.6% (n = 23) experienced controlling behaviors.Women with partners aged 25 years or younger were more likely to experience physical and/or sexual violence postpartum  reported physical and/or sexual IPV and 12.6% (n = 63) experienced psychological IPV and/or controlling behaviors both during pregnancy and postpartum. 13.8% (n = 69) of the participants reported experiencing physical and/or sexual IPV only during pregnancy, and 3.4% (n = 17) of them experienced physical and/or sexual IPV for the first time postpartum.Thus, 18.6% (n = 93) of the participants experienced postpartum physical and/or sexual IPV, which was a continuation of their pre-delivery experience. However, postpartum IPV was a new experience for a few women . There were marked differences between the victims and perpetrators in both sub-groups in terms of age, marital status and partner age. Women aged 21 years and younger experienced more physical and sexual IPV during pregnancy only  than their counterparts, while those between the ages of 22 and 35 years experienced new physical and/or sexual IPV postpartum . Single women experienced more physical and/or sexual IPV during pregnancy alone , while married women experienced more physical and/or sexual IPV postpartum . Men who were under the age of 25 years were less likely than their counterparts to be the perpetrators of physical and/or sexual IPV during pregnancy  and postpartum .This study found IPV during pregnancy to be more prevalent than IPV at one to nine months postpartum. It further found a 18.6% rate of physical and/or sexual violence during the index pregnancy and an 8% frequency postpartum. Controlling behaviors were the most prevalent form of IPV both during pregnancy (48.4%) and at one to nine months postpartum (44%), followed by psychological IPV .These rates are within the 2% to 57% range of different forms of IPV during pregnancy reported in a systematic review of African countries . HoweverTo our best knowledge, this is the first study to investigate psychological and economic abuse and controlling behavior during and after pregnancy in Tanzania. The high rates of controlling behavior and psychological and economic abuse are of great concern, as a study conducted among pregnant women in the USA found a strong link between psychological IPV and posttraumatic stress disorder . AdditioThe decline of IPV after one to nine months postpartum found in this study is consistent with some other studies which also reported a decline of IPV during the postpartum phase . HoweverThis study found that women are still likely to suffer postpartum IPV, even if they did not experience IPV during pregnancy. Although the postpartum IPV percentages might be smaller than those of IPV during pregnancy, such acts of violence still call for attention due to the potential adverse effects of IPV in the postpartum phase . There iIn the univariate analysis higher odds for women with partners aged 25 or younger was observed. This conforms to the findings of other studies. For example, IPV during pregnancy was associated with mothers’ younger age in Tanzania . MoreoveThis study has several limitations which have to be taken into account. First, it was a cross-sectional study and thus cannot establish a causal link between IPV during the pregnancy and postpartum. Second, since the study was conducted in urban health facilities in Dar es Salaam, the results cannot be extrapolated to represent the situation in the entire country. Additionally, due to the sensitive nature of the study in terms of social stigma and IPV being seen as a private matter, the participants may have underreported IPV. The exclusion of women accompanied by their partners may have resulted in an underrepresentation of severe cases of IPV, especially controlling behaviors.Although the study was cross-sectional, meaning recall bias was inevitable, participants were given clues to assist them in remembering what they went through during and after pregnancy. We also took steps to ensure we established rapport with the women so they could speak freely.The findings reveal that IPV is prevalent and the rates of controlling behavior are high both during pregnancy and postpartum. As highlighted in the results, maintenance and continuity of IPV persisted during pregnancy and postpartum. Some new cases of IPV emerged during the postpartum phase, but some IPV also stopped after pregnancy. These findings show that women can suffer IPV in these two phases of their life, which could lead to severe psychological and physical health implications. These results call for policy and interventions to be tailored to pregnant and postpartum women.S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S1 File(PDF)Click here for additional data file.


Violence related injury is a serious public health issue all over the world. This study aims to assess the association between several socio-economic factors and intimate partner violence (IPV) in Nepal.A cross-sectional study was conducted among 236 women working in carpet and garment factories in Kathmandu, Nepal. Interviews were conducted to collect quantitative data on three forms of IPV, namely physical violence, psychological violence and sexual violence, as well as on a number of potentially associated factors.p = 0.025 for physical IPV; OR = 6.94, p = 0.008 for sexual IPV; OR = 3.42, p = 0.043 for psychological IPV], alcohol consumption of the husband , education of the husband above primary level , and economic dependency of the woman on the husband .Twenty-two percent of women experienced sexual IPV, 28% physical IPV and 35% psychological IPV at least once in the last 12 months. The variables independently associated with at least one form of IPV were: age of the woman >29 years [OR = 4.23, This study identified various factors associated with IPV and showed that economic dependence of wives on their husband was among the most important ones. Thus, for the prevention of IPV against women, long term strategies aiming at livelihood and economic empowerment as well as independence of women would be suggested. Intimate Partner Violence (IPV) against women is a serious public health concern and a human rights issue worldwide –3. IPV rIn Nepal, IPV against women is encouraged due to the male dominance social system which discriminates against women and is also connected to cultural factors that limit women’s choices to leave a violent marriage . Women hThe risk for IPV in Nepal also seems dependent on various socio-economic factors. Most of the women from under-privileged castes and ethnic groups are at higher risk for IPV than women from higher castes . In addiIn the Nepalese context, economic dependency of women on their husband is generally high as compared to the western part of the world , which mTherefore, this study aimed at estimating the prevalence of physical, sexual and psychological IPV and at studying demographic, educational, social and economic factors associated with IPV among married women in the reproductive age between 15 and 49 years working in factories in Kathmandu.This cross-sectional study used a standardized, closed ended questionnaire administered orally by interviewers to married women of reproductive age (15–49 years) working in factories in Kathmandu, Nepal. Four carpet and garment factories were included in the study, because the carpet and garment industry is traditionally employing mostly women. The factories were selected on basis of convenience. The study population comprised of only married women currently living with their husband and the sample size calculation was done with OpenEpi software . The samThe total number of respondents included in the study was 236, as it was the required sample size of the study. Data collection was done using purposive sampling technique, meaning that sampling was done until the number of data reached the required sample size i.e. 236. Four factories were included to reach the required sample size. None of the eligible women refused to participate in the study nor did not complete the interview resulting in a response rate of 100%.The structured closed ended questionnaire was constructed by taking the reference from standard survey tools used by the Government of Nepal for the NDHS 2011 for collecting information about IPV at national level . The queThe first part of the questionnaire included general characteristics of women such as their age and their age at first marriage (>20 years/20 years or above according to NDHS ). The woThree forms of IPV were studied, namely physical violence, psychological violence and sexual violence. Physical violence included those acts causing physical harm such as hitting, beating, kicking, slapping, dragging or any form of physical injury. Psychological violence included those acts causing psychological harm such as insulting, threatening, humiliating or controlling on unnecessary activities and sexual violence, including forced sex. The time period for experiencing violence was during the last 12 months. The presence of any form of violence among those three types of violence was considered as the presence of IPV. The response was categorized binary as Yes and No.Psychological violence was assessed by the question: ‘Did your husband ever insult you or make you feel bad about yourself?’ Physical violence was assessed by a single question: ‘Have you ever been hit, slapped, kicked or done anything else to physically hurt by your husband at times?’ Sexual violence was assessed by a question: ‘Has your husband ever forced you to have sex when you did not wish to do so?’ The responses for all forms of IPV were in Yes/No form and for the severity assessment, the response options were ‘often’, ‘sometimes’, and ‘not at all’. The participants were also asked about their knowledge about IPV against women with the question: ‘Do you know what intimate partner violence is?’p < 0.05 for the Pearson value of the Chi-Square test was taken as indicating significance. Only factors significant in the Chi-Square tests (data not shown) were used in the bivariate logistic regression models presented in Tables Data was entered and analyzed in SPSS 22 for Windows. Chi-square tests were conducted to assess any association between the three forms of IPV and relevant socio-demographic factors. A significance level of Table Psychological violence was the form of violence most often reported and 35% reported that they had experienced psychological IPV by their husbands. Women, who reported that they were hit, slapped, kicked or physically harmed by their husband , included 28% of the respondents and 22% had suffered from sexual IPV.Table Table Several other variables only showed an association with sexual IPV, but only when not adjusted for the other variables in the table: women having more than 2 children, those having a love marriage, those with a lower level of education, those with a lower level of education of their husband, those who were economically dependent on their husband, those who had lack of knowledge about IPV and those who had decision making capacity were more likely to have experienced sexual IPV. However, all these associations became insignificant after adjusting for the other variables in Table Table Several other variables only showed an association with sexual IPV, when not adjusted for the other variables in the table: Women having more than 2 children, those who had a lower level of education and those who had a lack of knowledge about IPV were more likely to having experienced psychological IPV. However, all of these associations became insignificant after adjusting for the other variables in Table The first aim of our study was to study the prevalence of three different forms of IPV among female factory workers aged 15–49 years in Kathmandu Nepal. It was found that of 22% of women reported having experienced sexual IPV, 28% reported physical IPV and 35% reported psychological IPV at least once in their last 12 months. The NDHS 2011, a national level survey, reported slightly lower figures with 14% of women aged 15–49 years reporting sexual abuse by their husband at least once in their lifetime, 23% of them reporting physical abuse, one thirds of them reporting physical, sexual or psychological abuse once in their lifetime [As our second aim, this study focused on a number of relevant factors potentially affecting IPV which included age of women, age of women at their first marriage, number of children (parity), marriage type, education of women, education of husbands, economic dependence of women on their husbands, decision making capacity of women, knowledge about IPV on women and alcohol use of the husband. All these factors except for age of women at first marriage were significantly associated with the different types of IPV, but for most of the factors the association disappeared when adjusting for the other factors. The variables that were independently associated with at least one form of IPV were: higher age of the woman, alcohol consumption of the husband, low education of the husband and economic dependency of the woman on the husband. Out of these four variables, two of them showed a consistent association with all three forms of IPV even when adjusted for all other factors: higher age of women and alcohol use of the husband. Women whose age was 29 years and over had 3–7 times higher odds of having experienced psychological, physical or sexual IPV than younger women. The IPV risk for older women may increase due to more marital quarrelling that may be followed by violence , or oldeAlso, alcohol consumption of the husband was a strong independent risk factor for all forms of IPV. Alcohol consumption among men in Nepal is very high in comparison with the alcohol use of women . Our resEconomic dependence on the husband was found to be a risk factor for all forms of IPV in this study and after adjustment remained significant for physical and psychological IPV. Previous studies about the association between IPV and economic dependence of women on their husband also showed that the risk of violence against women was higher for women who were economically dependent on their husband . In NepaSeveral other factors showed some association with IPV, but only in the unadjusted models. E.g. women with an arranged marriage were less likely to report IPV. In Nepal, marriages that were arranged by their family are more frequent than love marriages and this type of marriage is also more secured by the families that arranged the marriage .Knowledge of women about IPV was found to be the protective factor for all forms of IPV in the study, but only without adjusting for other variables. A previous study about IPV conducted in Nepal concluded that women’s decision making autonomy was a strong predictor of IPV on women . HoweverWe also found that age at first marriage was not associated with any form of IPV and therefore the variable was not included in the logistic models. This is in line with another study, which describes causes of IPV showing that age at marriage was not associated with IPV .Our study has limitations and it is crucial to note that the data collection was cross-sectional and no conclusions regarding causal relationships can be drawn. The study population is also limited to factory workers in Kathmandu and the results may be different in rural areas or in other professional sectors. However, the response rate was extremely high which limits a potential selection bias towards only excluding women who may be absent from work due to IPV. Our study also relied on self-reported data and due to the fact that IPV and the associated factors are a sensitive issue, we cannot rule out potential under-reporting of IPV.In summary, we conclude that the prevalence of IPV is high in this group of women and that the odds of IPV was higher in women of higher age, for those with alcohol consumption of the husband, with low education of the husband and with economic dependency on the husband. Future research should identify underlying reasons for the high level of IPV.The findings from this study are important in order to make Nepalese women aware of the problem and to enable advocacy about IPV. A holistic approach is essential to gain family and community trust as well as support for women at the micro, meso and macro levels for the prevention and control of IPV issues in Nepal . The res


This paper investigates gender differences in persistence of intimate partner violence (IPV), for those remaining or leaving an abusive relationship. We followed a sample of males and females to examine whether leaving an abusive partner may alter the continuity of victimization.Data were taken from the 21 and 30-year follow-ups of the Mater Hospital and University of Queensland Study of Pregnancy (MUSP) in Australia. A cohort of 1265 respondents, including 874 females and 391 males, completed a 21-item version of the Composite Abuse Scale.We found proportionally similar rates of IPV victimization for males and females at both the 21 and 30 year follow-ups. Females who reported they had an abusive partner at the 21 year follow-up were more likely to subsequently change their partner than did males. Harassment and then emotional abuse appeared to have a stronger association for females leaving a partner. For males, a reported history of IPV was not significantly associated with leaving the partner. There was no significant association between leaving (or not) a previous abusive relationship and later victimization, either for male or female respondents.Changing a partner does not interrupt the continuity of victimization either for male or female respondents, and previous IPV victimization remained a determining factor of re-abuse, despite re-partnering. Intimate partner violence (IPV) may occur repeatedly in the context of some intimate relationships . There iPrior research following those who have previously experienced IPV has been limited and inconclusive. Only a small number of scholars have suggested that changing a partner may reduce IPV perpetration , 8 and vlife course perspective suggests that particular periods of the life course may be associated with higher rates of IPV. Characteristics of early adulthood  contribute to a greater risk of IPV in this period. Afterwards, developmental changes  may protect individuals from subsequent victimization/ perpetration- regardless of leaving or staying with a partner victimization and staying in an abusive relationship, are related to the following factors: marital status, lower socio-economic status, presence of children, history of child abuse, and poor mental health , 39–43.what is your present marital status? Categories comprised single/never married, living together, married or separated. Education levels included high school or less, diploma and college and university. Having a child was dichotomized into yes and no. Participants were asked about their family income which was defined as gross income before tax. Then using the Australian National Poverty Line as a guide [low income and the rest into higher income. For measuring history of sexual child abuse 21-year respondents were asked whether they had experienced being pressured or forced to have sexual contact before they were 16 years. Depression was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) which is a widely-used self-report scale [during the last 12 months have your sexual partners been: only the opposite sex, only the same sex and both sexes. We then categorised respondents into two categories of heterosexual and homo/bisexual.All participants were about 21 and 30 years of age at each follow up, so we did not adjust for the age differences in the cohort. Marital status was measured by the question  a guide , we catert scale . It contrt scale , 47. Sexp-value< 0.05 for significance. In Table In Table Among 1265 21-year-old participants who were in a relationship, 6.1% were married and 93.9% were living together. 11.1% of respondents had children.p = 0.07) is experienced more often by females. By contrast, 21-year-old males more frequent report being physically abused. At 30, there are no gender differences in any form IPV.Table Table Table A further detailed analysis (data not shown) suggests that although the association between having children and females’ leaving their partners is negative Table , when moTable p = 0.08). For females we note that 55.7% of those experiencing IPV changed partners, while 42.9% of those not experiencing IPV changed partners (p <  0.001) by the 30 year follow up. Females who reported IPV at 21 years and remained with their partners, were no more likely to be abused at 30 years compared to females who had changed partners . A further interaction terms between the experience of IPV at 21 (non-abused/abused) as primary variable and change of partner (stay/change) as moderator was conducted to predict the experience of IPV at 30 (non-abused/abused) separately for females and males (data not shown in a table). Consistent with the findings in Fig. 95 = 0.44–1.35). In contrast, the primary effect of experiencing IPV at 21 remains a robust significant predictor for experiencing IPV at 30 years. For males, no statistically significant difference in experiencing IPV at 30 years is observed between males who left their abusive or non-abusive partners . These findings were independent of a range of potential confounding factors.Figure p <  0.00 by the 3The current study has compared males and females in the continuity of IPV victimization at 21 and 30 years of age. A cohort of 1260 cases was followed to determine whether early IPV victimization was associated with leaving the prior partner and subsequent IPV. In addition, we followed both males and females to examine how a change of abusive partners may alter the continuity of victimization.p <  0.0001). Despite this decline in the IPV rate across time, there was a robust significant association between early victimization and re-victimization for both males and females. We also found that a substantial proportion of females (55.7%) and males (51.0%) who report experiencing IPV at 21 years left their partners (p > 0.05). Victimized males at 21 years were no more likely to change partners, than those not experiencing IPV at 21 years. These findings were not affected by any of the sociodemographic factors that were considered. Harassment and then emotional abuse appeared to have a higher association with leaving partner in females. Relationship change did not appear to prevent males and females from the continued experience of victimization. We found experiencing IPV at 21 remains a robust significant predictor for experiencing IPV at 30 years, regardless of whether there is a change of partner.The results of this study suggest that rates of IPV victimization declined from 21 to the 30 year follow up . Features of this life course stage include instability  and tendency to postpone adults’ responsibilities , which may contribute to a higher rate of IPV victimization at this period [The observed decline in IPV victimization from 21 to 30 years may reflect the longer period in which 21-year respondents were asked about their experiences, compared to that of 30 years (last year). Nevertheless, this finding is consistent with a s period , 12, 13.s period .A relationship between early and further victimization supports previous research which suggests that earlier victimization may be taken to mean violence is considered a normal aspect of intimate relationships. Prior experiences of family violence may lead to cumulative disadvantages  which negatively affect the nature of future relationships , 48–51.Slightly higher rates of leaving the abusive partner in females seems to be consistent with other research indicating that females have disproportionately higher rates of relationship termination than males . ConsideWe also found no support for the effectiveness of leaving an abusive partner. This finding is in line some previous studies which find no significant difference between those who stayed or changed partners , 15. HowA body of research has shown that earlier victimization may lead to long-lasting consequences for survivors like fear, posttraumatic stress, anxiety and disempowerment . SurvivoThis study has several strengths: IPV was assessed by a validated measure at 21 and 30 years. We also used the longitudinal data from a large prospective cohort of both males and females and adjusted for a range of confounding factors. We have found that leaving an abusive relationship makes no significant difference to experiencing further IPV and early IPV victimization remains the strongest predictor of re-abuse, despite changing partner. The current work has extended existing knowledge about IPV victimization experienced in relationships with different partners. Our findings raise the question of whether there are characteristics of those affected by IPV and socio-cultural factors, not measured in this study, that need to be identified and addressed if IPV and its consequences are to be reduced.gender specific IPV interventions. For example, we found similar rates of IPV for 30-year-old males and females and no association between the experience of IPV and males’ leaving their partner. These findings leads to a recommendation that gender-specific prevention efforts should put greater emphasis on males’ IPV victimization and their decision to stay in an abusive relationship.The findings of this study have significant implications for IPV reduction programs: first, gender differences in predictors of IPV and in its association with leaving a partner raise the need for early IPV prevention. If it is possible to prevent first victimization experiences, then the subsequent victimization may be avoided [The finding that early IPV victimization remained a determining factor of revictimization highlights the need for  avoided . More imIPV interventions which protect and assist those affected by IPV, should address complex needs of survivors. For example, in the current study, depression was a significant predictor of both changing partner and IPV victimization. Clinical intervention efforts are required to target pre-existing as well as subsequent mental health problems of victims to minimize the risk of further abuse. Having a low income was also a significant barrier against abused females to leave an abusive partner. IPV interventions should therefore consider the policy of women’s financial empowerment .This study has a number of limitations: The data were collected using a self-report measure from one partner, which may associated with self-serving bias or over-reporting negative behaviours of partners. In addition, at 21 years respondents reported their life-time IPV in either their current or previous relationships, while at the 30 year follow up, they described their most recent relationships during last 12 months . Males’


Background: Although various types of intimate partner violence (IPV) tend to co-occur, risk factors of each type of IPV may differ. At the same time, most of the existing literature on risk factors of IPV among minorities has used a cross-sectional design and has focused on physical rather than sexual IPV. We conducted the current study to compare Black and Hispanic women for psychological predictors of change in sexual IPV over time. Methods: Using data from the Fragile Families and Child Wellbeing Study (FFCWS), this study followed 561 Black and 475 Hispanic women with their male partners for four years. Independent variables included male partners’ depression, anxiety, problem alcohol use, and male-to-female physical and psychological IPV perpetration. The dependent variable was sexual IPV reported by female partners, measured at baseline, two years, and four years later. Covariates included age, income, marital status and education level. We used a multi-group latent growth curve model (LGCM) to explain intercept, linear, and quadratic slopes, which represent the baseline, and linear and curvilinear trajectories of male-to-female sexual IPV, where groups were defined based on ethnicity. Results: Psychological IPV was associated with sexual IPV at baseline among both ethnic groups. The male partner’s depression was a risk factor for an increase in sexual IPV over time among Black but not Hispanic women. Anxiety, problem alcohol use and physical IPV did not have an effect on the baseline or change in sexual IPV over time. Psychological IPV was not associated with an increase in sexual IPV over time in either ethnic group. Conclusions: There is a need for screening of sexual IPV in the presence of psychological IPV among minority women. There is also a need for screening and treatment of male partners’ depression as a strategy to reduce sexual IPV among Black women.Background: Although various types of intimate partner violence (IPV) tend to co-occur, risk factors of each type of IPV may differ. At the same time, most of the existing literature on risk factors of IPV among minorities has used a cross-sectional design and has focused on physical rather than sexual IPV. We conducted the current study to compare Black and Hispanic women for psychological predictors of change in sexual IPV over time. Methods: Using data from the Fragile Families and Child Wellbeing Study (FFCWS), this study followed 561 Black and 475 Hispanic women with their male partners for four years. Independent variables included male partners’ depression, anxiety, problem alcohol use, and male-to-female physical and psychological IPV perpetration. The dependent variable was sexual IPV reported by female partners, measured at baseline, two years, and four years later. Covariates included age, income, marital status and education level. We used a multi-group latent growth curve model (LGCM) to explain intercept, linear, and quadratic slopes, which represent the baseline, and linear and curvilinear trajectories of male-to-female sexual IPV, where groups were defined based on ethnicity. Results: Psychological IPV was associated with sexual IPV at baseline among both ethnic groups. The male partner’s depression was a risk factor for an increase in sexual IPV over time among Black but not Hispanic women. Anxiety, problem alcohol use and physical IPV did not have an effect on the baseline or change in sexual IPV over time. Psychological IPV was not associated with an increase in sexual IPV over time in either ethnic group. Conclusions: There is a need for screening of sexual IPV in the presence of psychological IPV among minority women. There is also a need for screening and treatment of male partners’ depression as a strategy to reduce sexual IPV among Black women. Although both genders commit intimate partner violence (IPV) against their partners, male-to-female IPV is more common than female-to-male IPV . There aSexual IPV includes a wide range of experiences, from coercion to unwanted sexual activity by a partner to more severe forms, such as rape. Up to 21% of women experience sexual IPV . Women wBased on the literature, sexual, psychological, and physical IPV tend to co-occur ,12,13. TExposure to sexual coercion, threats of violence, and physical violence often co-occur in women . VictimsWhile research on the topic is limited, we have reason to believe that anxiety acts as a possible risk factor for perpetration of IPV ,29,30. VAlcohol misuse also increases the risk of IPV perpetration among men ,32,33,34Using a dyadic approach that includes both partners as informants , the curThis study used interview data from Waves 2 through 4 of the Fragile Families and Child Wellbeing Study (FFCWS), an ongoing longitudinal, population-based cohort, which began in 1998 ,41,42. TThe study was approved by Institutional Review Board Committees at Princeton University and Columbia University. Verbal and written informed consent was obtained from participants at each interview, and all participants were compensated for their involvement in the study.The FFCWS used a random sampling method from families in 20 U.S. cities with populations of 200,000 or more. A detailed description of sampling strategy and interview protocol in the FFCWS is available elsewhere . The FFCWe limited the current analysis to couples in which the female partner was either Black/African American or Latino/Hispanic. As a result, 1036 of 4898 total participating couples from different ethnic groups who completed the baseline of the study were entered into the current analysis.Data used here were limited to the parental core interviews, interviews with the mother and father reporting on child health and development, and their own romantic relationships with the other parent and marriage attitudes. The term “parental core interview” is used to distinguish interviews with parents from interviews with a primary caregiver, which may include caregivers other than parents . ParticiMale-to-female sexual IPV. Sexual IPV was assessed by asking female partners “How often does the father (of your baby) force you to have sex/do sexual things?” Response items included never (0), sometimes (1), or often (2). This item was adapted from the Spouse Observation Checklist  and studMale-to-female physical IPV. Physical IPV was assessed by asking female partners two questions on a 3-point scale , regarding how often fathers carried out behaviors toward the female partner  and were adapted from the Conflict Tactics Scale (CTS-2) for adults ,56. The Major Depressive Disorder (MDD). The Composite International Diagnostic Interview-Short Form (CIDI-SF) was used to measure MDD . The CIDGeneralized Anxiety Disorder (GAD). The CIDI-SF was used to screen for symptoms consistent with a diagnosis of GAD . The diaProblem Alcohol Use. Heavy/problem alcohol use was defined as five or more drinks during a single day over the past month (coded “1”). This measure approximates heavy drinking according to the definition by the National Institute on Alcohol and Alcoholism, i.e., five or more drinks in a single day for men . Based on this model, MDD in male partner (at baseline) was associated with a larger linear slope for trajectory of sexual IPV during four years of follow up . Psychological IPV at time 2 was also associated with higher sexual IPV at time 2. Male partners’ age, education level, income, ethnicity, GAD, problem alcohol use and physical IPV were not significantly associated with baseline, linear, or quadratic slopes of sexual IPV over time . Male partners’ age, education level, income, ethnicity, MDD, GAD, problem alcohol use and physical IPV were not significantly associated with sexual IPV at wave 2 or linear or quadratic slopes of sexual IPV over time (Model 2 corresponds to Hispanic women and their partner /spouse. The model showed a good fit to the data [ver time .This study showed similarities and differences in psychological predictors of sexual IPV against Black and Hispanic women. A similar association between psychological and sexual IPV was found for both Black and Hispanic women. Male partners’ depression was associated with a worse trajectory of sexual IPV over the follow-up period among Black, but not Hispanic women.We found ethnic variation in the effects of depression in male partner, meaning the effect was present in Blacks but not Hispanics. Ethnic variations in the associations between psychosocial risk factors and behavioral health outcomes are shown across domains ,62,63,64Our finding on the effect of male partner depression on sexual IPV is supported by literature that shows psychopathology increases the risk of IPV perpetration ,21. AngeOur study did not show that male partner’ problem drinking behavior had any effect on sexual IPV victimization of Black or Hispanic female partners. In a study in Russia, the odds of IPV perpetration were three times greater among men who misused alcohol than those who did not . CommuniFurthermore, alcohol use disorder was reported as the strongest associated factor of IPV perpetration in a study conducted by Smith, Homish, Leonard, and Cornelius . CompareOur study did not find that male partners’ presentation of GAD had any effect on sexual IPV against Black or Hispanic women. Again, most studies which have built our current understanding of the association between anxiety and IPV perpetration are limited to other types of IPV. In a study by Miga et al. , attachmOur study has four policy and clinical implications. First, as this was a community sample, rather than a clinical sample, and as minority populations have greater stigma and lower access to health care, there is a need for screening and treatment programs in the community. The first implication of our results is a need for community-based intervention to prevent of IPV in ethnically diverse communities.Second, we found that psychological and sexual IPV co-occur, regardless of ethnicity. This finding suggests a need for combined programs which can help protect women of minority status against experiences of IPV through preventative and treatment programs. Research findings on risk factors and protective factors contributing to co-occurring physical and sexual IPC may collectively contribute to reducing ethnic disparities in the burden on IPV among women.Third, based on our findings, there is a need to screen male perpetrators for mental health issues, and other types of IPV, particularly psychological IPV. This is an important distinction from prior approaches to identifying and addressing IPV, which have primarily focused on the screening of victims.  Our findAs stated, our research findings provide evidence for the importance of mental health screening of male perpetrators, in addition to female victims. A fourth implication of our study is, as psychological and sexual IPV victimization tend to co-occur among minority individuals, we propose combined programs that simultaneously address various types of IPV. Interventions aimed at the prevention of IPV may benefit from combined programs that target various forms of IPV, including sexual violence. We believe that prevention strategies may benefit from studies that focus on both of these outcomes.The current study had four significant limitations. Firstly, female victims may underreport sexual IPV, which is particularly significant for low SES and minority populations who may suffer from greater stigma in reporting. Low SES and minority status may reduce IPV disclosure ,89,90. SAdditional research is needed to understand why, how, and when women of diverse ethnic minority groups are exposed to a combination of psychological and sexual IPV. A suggested first step would be testing psychological IPV as a possible mediator for the effect of risk factors on sexual IPV. In addition, there is a need to test the efficacy of interventions meant to improve the mental health of male partners as a strategy to prevent male-to-female IPV. Future research should add clinical interviews and more contextual data along with standard measures .Black and Hispanic women showed common and unique psychological determinants of sexual IPV. Psychological IPV was similarly associated with sexual IPV among both ethnic groups. Male partners’ depression was a risk factor for sexual IPV among Black but not Hispanic women. Combined programs that jointly screen for sexual and non-sexual IPV are needed among minority women, regardless of their ethnicity. There is also a need for attention to male partners’ psychopathology in the presence of sexual IPV reported by Black women.


Understanding the past-year prevalence of male-perpetrated intimate partner violence (IPV) and risk factors is essential for building evidence-based prevention and monitoring progress to Sustainable Development Goal (SDG) 5.2, but so far, population-based research on this remains very limited. The objective of this study is to compare the population prevalence rates of past-year male-perpetrated IPV and nonpartner rape from women’s and men’s reports across 4 countries in Asia and the Pacific. A further objective is to describe the risk factors associated with women’s experience of past-year physical or sexual IPV from women’s reports and factors driving women’s past-year experience of partner violence.This paper presents findings from the United Nations Multi-country Study on Men and Violence in Asia and the Pacific. In the course of this study, in population-based cross-sectional surveys, 5,206 men and 3,106 women aged 18–49 years were interviewed from 4 countries: Cambodia, China, Papua New Guinea (PNG), and Sri Lanka. To measure risk factors, we use logistic regression and structural equation modelling to show pathways and mediators. The analysis was not based on a written plan, and following a reviewer’s comments, some material was moved to supplementary files and the regression was performed without variable elimination. Men reported more lifetime perpetration of IPV  than women did experience , but women’s reports of past-year experience  were not very clearly different from men’s . Women reported much more emotional/economic abuse (past-year ranges 1.4%–5.7% for men and 4.1%–27.7% for women). Reports of nonpartner rape were similar for men (range 0.8%–1.9% in the past year) and women (range 0.4%–2.3% in past year), except in Bougainville, where they were higher for men (11.7% versus 5.7%). The risk factor modelling shows 4 groups of variables to be important in experience of past-year sexual and/or physical IPV: (1) poverty, (2) all childhood trauma, (3) quarrelling and women’s limited control in relationships, and (4) partner factors . The population attributable fraction (PAF) was largest for quarrelling often, but the second greatest PAF was for the group related to exposure to violence in childhood. The relationship control variable group had the third highest PAF, followed by other partner factors. Currently married women were also more at risk. In the structural model, a resilience pathway showed less poverty, higher education, and more gender-equitable ideas were connected and conveyed protection from IPV. These are all amenable risk factors. This research was cross-sectional, so we cannot be sure of the temporal sequence of exposure, but the outcome being a past-year measure to some extent mitigates this problem.Past-year IPV indicators based on women’s reported experience that were developed to track SDG 5 are probably reasonably reliable but will not always give the same prevalence as may be reported by men. Report validity requires further research. Interviews with men to track past-year nonpartner rape perpetration are feasible and important. The findings suggest a range of factors are associated with past-year physical and/or sexual IPV exposure; of particular interest is the resilience pathway suggested by the structural model, which is highly amenable to intervention and explains why combining economic empowerment of women and gender empowerment/relationship skills training has been successful. This study provides additional rationale for scaling up violence prevention interventions that combine economic and gender empowerment/relationship skills building of women, as well as the value of investing in girls’ education with a view to long-term violence reduction. In a cross-sectional analysis of survey data from Cambodia, China, Papua New Guinea, and Sri Lanka, Rachel Jewkes and colleagues compare women's and men's reports of past-year prevalence of intimate partner violence and rape. Understanding the past-year prevalence of physical and or sexual intimate partner violence (IPV) and risk factors is essential for building evidence-based prevention.Previous studies have not compared men’s and women’s past-year prevalence reports and have been limited by a predominant focus on risk factors for lifetime exposure to IPV.Monitoring SDG 5.2 and building evidence-based prevention require a relative understanding of the measures of past-year prevalence and the drivers of this violence.We use data from 4 countries of the UN Multi-country Study on Men and Violence in Asia and the Pacific to compare the population prevalence rates of past-year IPV and nonpartner rape from women’s and men’s reports and present an analysis of drivers of women’s experience of past-year physical or sexual IPV.Women’s reports of past-year male-perpetrated IPV were similar to those from men.Four groups of variables are important drivers of IPV: poverty, all childhood trauma, quarrelling and women’s limited control in the relationship, and partner factors .Past-year IPV indicators based on women’s reported experience that were developed to track SDG 5 are probably reasonably reliable.Women appear to gain resilience to violence through combined economic power and understanding gender empowerment/relationship skills, as well as education; this is an important foundation for intervention.Further research is needed on the validity of men’s and women’s reports of IPV, which could not be determined from these data. In 2015, eliminating all forms of violence against women and girls (VAWG) was adopted as a target for the Sustainable Development Goal (SDG) 5 on gender equality and empowerment of women. To achieve this, we must develop and roll out effective measures to prevent male-perpetrated violence and show their effect. The indicators of progress towards this target are not finalized but will be a measure of women’s experience of intimate partner violence (IPV) and of nonpartner sexual violence in the past 12 months. According to most recent estimates, 30% of women aged 15 years and over have experienced male-perpetrated physical and/or sexual IPV, and 7% nonpartner sexual violence, in their lifetime [In low- and middle-income countries, the World Health Organization instrument that was developed for its Multi-country Study on Women’s Health and Domestic Violence against Women is generally seen as the gold standard measure for women. Parallel research with men has developed a methodology for measuring perpetration, but the 2 measures of violence in heterosexual relationships have not been compared. Given that widely used indicators will most likely focus on reports of just 1 gender for reasons of resource constraints, it is important that there be an understanding of the comparability of men’s and women’s reports. Without this, we have uncertainty about the validity of women’s reports of experiences of IPV and nonpartner sexual violence. There is particular concern that sexual violence may be under-reported by women because rape is highly stigmatized, which may result in minimization of events, but it is also possible men might under-report perpetration of violence so as not to incriminate themselves ,4.Prevention of VAWG needs to be built on evidence of drivers among women currently at risk (as well as those of perpetration). There is a reasonably large amount of literature on risk factors for experience of IPV , but maThe UN Multi-country Study on Men and Violence was designed to address many of the gaps in previous data sources . It has Ethical approval was provided by the Medical Research Council of South Africa; the College of Humanities, Beijing Forestry University; National Ethics Committee for Health Research of Cambodia; and the Faculty of Medicine at the University of Colombo, Sri Lanka.The survey was developed by Partners for Prevention in collaboration with the Medical Research Council of South Africa and the country research teams. Research was conducted in 2011–2012. Of the 6 country surveys, only 4 had male and female interviews: China, Cambodia, Bougainville in Papua New Guinea, and Sri Lanka. The present study is intended to contrast women's reported experience of IPV and nonpartner rape with men's reported perpetration of IPV and nonpartner rape; therefore, our analysis focuses on these 4 surveys. The sample from Cambodia and the sample from Papua New Guinea were representative, respectively, of Cambodia and the island of Bougainville. The Chinese site was a county with a town and rural area, and in Sri Lanka, Colombo and 3 contrasting districts were surveyed. Further details of the research can be found elsewhere ,10.In each setting, we selected census enumeration areas, with a probability proportionate to size, and systematically selected households within these areas. In households, we invited a man or woman (depending on the cluster) aged 18–49 years  for interview, with a trained sex-matched interviewer. Most interviews were face to face, but for men, answers to most sensitive questions were self-completed on audio-enhanced personal digital assistants (APDAs). In China, a household list of individuals in each cluster by age and sex was available and used for sampling within selected clusters, and the entire questionnaire was self-completed. Full details of the methods, sampling, and response rates are presented elsewhere . We condThe data analysis was largely planned at the point of commencement of the work on the paper. Authors EF and RJ were involved in the research from its inception and had planned the questionnaire so that it would be possible to undertake an analysis of prevalence of violence and risk factors. They ensured as much as possible that the main variables previously described in the literature  were incWe combined the datasets and analysed the data using Stata, version 13. All procedures took into account the multistage structure of the dataset, with stratification by site within a country and enumeration areas as clusters. The sample was self-weighting. Women’s experiences of violence and male partner violence perpetration, as well as the independent variables, were summarized as percentages (or means), with 95% confidence limits calculated using standard methods (Taylor linearization).We categorised the type of violence exposure according to the most severe type experienced, where greatest severity was considered as exposure to physical and/or sexual IPV, as this is the category that has been the basis of most health consequences research  and is cThe multiple emotional/economic abuse category consisted of women who had experienced more than 1 act of economic or emotional abuse but never experienced sexual or physical abuse. All ever-partnered women and men were classified into 5 violence exposure categories: none, emotional/economic without sexual or physical , sexual without physical and with or without emotional/economic , physical without sexual and with or without emotional/economic , or sexual and physical with or without emotional/economic .We also evaluated the relationship between the outcome (IPV) and nonresponse (missing data) in putative risk factors. No association was found between a woman’s IPV status and her nonresponse to any of the possible risk factors. However, to increase the sample of women with responses to scale measurements , women with partial responses to scale items were also included. Three methods for imputing for missing data were initially compared. These involved imputing for missing scale items using either (1) a woman’s responses to other items in the scale  or (2) the average for each item adjusted for IPV status, or (3) the average of the overall score adjusted for IPV status. There were no significant differences in the 3 methods for both gender attitudes and relationship control scores. We used ‘the average of the overall score (adjusted for IPV status)’ to impute for missing scores.The exercise of testing variables and building model drew on current theories about risk factors and drivers of violence against women. The selection of variables as putative risk factors was informed by the state of knowledge in the field. Drawing on a life-course modified ecological model of violence risk , we concTo show associations between independent variables that were putative risk factors, we first conducted a bivariable analysis with a (by type) lifetime IPV exposure measure and a multinomial regression with no physical, sexual, or severe economic/financial violence as the comparison group. A maximum likelihood multinomial logit model, which adjusted for the survey design, was used to compare factors associated with different types of IPV experienced with the no-violence reference category. We initially fitted bivariable models and then included all factors that were significantly associated with IPV experience in the bivariate models into an overall model, which was adjusted for the country and age group of the woman.We examined factors associated with past-year experience of IPV considering the same independent variables, but with a past-year exposure to any physical and/or sexual IPV as the outcome, due to sample size considerations, we did not perform multinomial modelling. We sought to model 19 covariates in the logistic regression model, which, according to generally accepted rules of thumb , would rP < or = 0.05 in the model, which is adjusted for country/site and age-group of the woman.Multivariable logistic regression was used to determine risk factors associated with past-year physical and/or sexual IPV experience in women, with those not experiencing this as the reference group. To enable the use of a variable on frequency of quarrelling, which was not measured in Cambodia, a dummy level for Cambodia was created for the quarrelling variable for use in the logistic regression model. All variables were included in the multivariate analysis. We focus the discussion on variables with The population attributable fractions (PAFs) for each category of IPV were calculated using the formula PAF = ((RRR − 1) / RRR) * Pe, where RRR is the adjusted relative risk ratio from the adjusted model and Pe is the proportion of women who had experienced that particular IPV type and who had the exposure.Structural equation modelling (SEM) was conducted using Stata 13.0 to assess the interrelationship between variables associated with physical and/or sexual IPV in the multinomial regression model. The model outcome was a past-year IPV variable that had 4 levels drawn from the physical and sexual IPV questions: no exposure, sexual IPV, physical IPV, and physical or sexual IPV. The correlation between each hypothesized variable and the IPV variable was then tested by building variable pairs. All associations were tested by running a full-information maximum likelihood method to deal with missing values. This method was chosen over multiple imputations because it has been shown to yield superior results in structural equation modelling . As a neP < 0.05 level) from the exogenous variables to IPV in order to ensure model parsimony. Before adjusting standard errors for clustering of participants in countries, model fit was very good (p(χ2) = 0.519, RMSEA < 0.001, CFI = 1.000, and TLI = 1.001). After adjusting for clustering, the coefficient of determination (CD) was 0.215. The model did not include any error covariances.We fitted a path model using full information maximum likelihood (FIML) estimation to model all available data. The final model was built based on theory and statistically meaningful modifications using backwards elimination to exclude endogenous variables that did not mediate any path  were ever-partnered. Of the ever-partnered women, 90 (3.3%) did not respond to any of the questions related to IPV experience and were thus excluded from analysis. In total, 5,206 men were interviewed in the 4 countries, and 4,360 (83.8%) had ever been partnered. Four thousand and fifteen men completed the IPV questions, and 5,062 completed the non-partner rape questions.Comparing lifetime reports of women’s experiences and men’s reports of IPV by type from the 4 countries  reveals In Cambodia, 0.4% (95% CI 0.1%–1.73%) of women had experienced nonpartner rape in the past year, and 1.9% (95% CI 1.12%–2.70%) of men disclosed perpetration. In China, 2.3% (95% CI 1.49%–3.43%) of women had experienced nonpartner rape in the past year, and 1.7% (95% CI 0.94%–2.52%) of men disclosed perpetration. In Bougainville, 5.7% (95% CI 4.21%–7.75%) of women had experienced nonpartner rape in the past year, and 11.7% (95% CI 9.02%–14.30%) of men disclosed perpetration. In Sri Lanka, 0.5% (95% CI 0.15%–1.40%) of women had experienced nonpartner rape in the past year, and 0.8% (95% CI 0.22%–1.43%) of men disclosed perpetration.P < 0.001) as those in which the husband provided, another provided, or both the husband and wife shared equally in providing.The prevalence of past-year physical and/or sexual IPV experience increased with age . PovertyAll 3 forms of childhood abuse  and witnessing abuse of mother were more common among women with past-year physical or sexual IPV experience. Women whose partners earned more than them had a lower past-year IPV prevalence than those earning the same as their partners or women who earned more. Partner characteristics associated with women’s past-year IPV experience were the male partner’s regular alcohol use, ever or past-year drug use, lack of fidelity, and unemployment. Women who were highly controlled by their partner were more likely to have experienced past-year IPV, as were those who quarrelled more often and those holding less gender-inequitable views.Results for the structural equation model are presented in Between a quarter and two-thirds of women in the 4 countries studied had experienced IPV, and 1.7% and 15.9% had experienced nonpartner rape. There was very great diversity in the prevalence of IPV between countries, as previously reported in Asia and the Pacific [We would not necessarily expect men’s and women’s reports of nonpartner sexual violence to concur, and some women are at much higher risk than others in the population and may experience multiple rapes . AlthougWe saw 4 important groups of risk factors for IPV experience. First, our results confirm that past-year IPV victimisation is more common in a context of poverty . SecondlWitnessing abuse of one’s mother has been found to be associated with both experience of and perpetration of IPV in many studies ,28–35. WThe third variable group consists of partner characteristics: his drinking, past-year drug use, controlling behaviour, unemployment, and fidelity. Generally, these are previously well-established risk factors, although research with men has not confirmed associations with drug use in Asia and the Pacific, except in relation to perpetration of multiple perpetrator rape ,10. AlcoThe frequency of quarrelling was very strongly associated with IPV, as it was in the models of men’s perpetration in the 4 countries . AlthougOne of the most important findings of the structural model was a pathway that can be interpreted as indicating variables that build women’s resilience to violence. This linked higher wealth, higher educational attainment, and having more gender-equitable attitudes. This is very important because all of these factors are amenable to intervention, and it highlights the role of poverty reduction and interventions to enhance girls’ schooling, which may be supported for many reasons related to development and the general upliftment of women, in IPV prevention. In this study, the Gender Equitable Men (GEM) scale was used to measure women’s gender attitudes. This is a broad measure that includes attitudes towards the use of violence against women. The latter alone have been shown to be very strongly associated with risk of violence ,42; howeEconomic empowerment has been shown to be a fruitful area of intervention with women , but morReducing childhood trauma exposure is ultimately critical to reducing women’s experience of violence and is strongly related to poverty. Whilst there is much work on early interventions in childhood to reduce the experience of trauma and IPV in the next generation, it is possible that poverty reduction will have the greatest impact.The study findings reflect the sampled sites; generalizability beyond this is unclear, and the combined dataset analysed here does not reflect the whole region. Since the research was cross-sectional, temporality may be questioned, but since this was recent violence, this is not likely to be a great problem. All the prevalence estimates for violence were compared with estimates weighted for the number of eligible men and women per household. The latter were not significantly different in any site, and thus, we have used unweighted estimates. The main analysis was on past-year IPV exposure, and because this is less common than lifetime exposure, the power of the analysis was inevitably impacted. However, the focus has strengthened the interpretability of the results for programming, as it is the goal of IPV prevention to reduce exposure of women at risk in the future and recent abuse is the best measure of this. A study limitation is that we do not have a comparison of men’s and women's reports from the same relationship. In accordance with WHO ethics and safety guidelines, we did not interview men and women in the same location, much less in couples. The motivation is to avoid the  possibility of retaliatory violence associated with partners learning of the interview content. This risk is not justified in cross-sectional research but prevents comparison of couples’ reports.Our findings suggest that newly emphasised past-year IPV indicators that were developed to track SDG 5 would be reasonably reliable if based on women’s interviews. Interviews with men to track past-year nonpartner rape perpetration are important. We have shown an important IPV resilience pathway. This helps us to understand why interventions that combine women’s economic empowerment and building gender-equitable attitudes (and communication skills), such as Pronyk and colleagues’ Image , may be S1 Fig(TIF)Click here for additional data file.S1 STROBE ChecklistChecklist of items that should be included in reports of cross-sectional studies.(DOC)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.