Investigating the relationship between intimate partner violence, reproductive health and pregnancy outcome: a systematic review

Abstract

Introduction

Intimate partner violence (IPV) is a universal problem that exists in most countries of the world. Worldwide, one third of women will experience physical or sexual violence in their lifetime, mainly by intimate partner. IPV can affected on reproductive health and lead to serious injury and death of mother and baby. Current systematic review was conducted with the aim of determining the relationship between intimate partner violence, reproductive health and pregnancy outcome.

Material and methods

Study performed based on “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) by PICO components. The literature review was conducted using the electronic medical databases were searched using the equivalent keywords without starting time limit, up to January 2024. Medical subject headings with Boolean operators, and the proportionate keywords as follows: (fertility OR pregnancy OR child bearing) AND (intimate partner violence OR domestic violence) in title, abstract and keywords of articles were used. Inclusion criteria were published observational studies and clinical trials in English language. Studies participants considered women with a history of IPV and fertility as an outcome. Data extracted according to a predefined checklist. Two investigators independently examined title, abstract, and full-text screening. The study selection, quality assess, and extraction of data were independently by two researchers. Inconsistencies resolved by a third researcher.

Findings

A total of 1834 documents were retrieved that finally; 39 articles were reviewed. About 50% of the articles were related to the last five years. Relationship between IPV and intention to have children through “unwanted and unintended pregnancy”, “contraception use”, “contraception use and types of IPV and unmet need for contraception use” has a contradictory effect.

Additionally, relationship between IPV and pregnancy outcomes through “maternal health”, “pregnancy”, “number of children and childbirth intervals” and “fetal outcomes” has a contradictory effect in different ways. According to the results, women subjected to violence may face an increased risk of pregnancy complications, abortion, stillbirth and infant death. Also, intimate partner violence may increase the incidence of induced abortion among women experiencing violence.

Conclusion

According to this review study, intimate partner violence can affect the reproductive health, and pregnancy outcome. Therefore, violence against women by the husband should be given more attention and solutions should be considered at the social and individual level for improve the reproductive health and pregnancy outcome.

Introduction

Intimate partner violence (IPV) is a global phenomenon that exists in most countries of the world [1]. Worldwide, 1/3 women experiences physical, or sexual violence in their life, which is referred as IPV. This is a clear case of gender inequality and discrimination against women [2]. The experience of violence is varying according to women’s race, ethnicity, age, nationality, education level, family, social status and employment, ability level, and gender. Furthermore, in all cultures, men are the main perpetrators of violence [3, 4]. Feminist research emphasizes that domestic violence is the result of patriarchal views. This view empowers society and the system to empower men to dominate and control women [5]. Domestic violence is relevant to an interwoven and complex set of factors. The most important of these factors are the patriarchal perspective, cultural beliefs, community norms, and education levels [6].‏ The patriarchal view arose from the ideology of masculinity, attitudes, beliefs, and behaviors related to patriarchy learned during the process of socialization [7]. According to the “Diagnostic and Statistical Manual of Mental Disorders” (DSM-IV), the risk of developing depression and post-traumatic stress disorder following a traumatic event depends on several factors, including the type of trauma, and aggressive violence is the most common factor [8, 9]. Women after exposed to danger more likely to suffer from post-traumatic stress disorder [10]. At the same time, IPV is less reported and known in the health sector. Health professionals rarely inquire about IPV and women are not interested in revealing their experience [9]. In studies, it has been observed that victims of intimate partner violence (IPV) are often hesitant to disclose [11]. Only 21% of women report their victimization to a doctor or nurse [12].

This may be due to reasons such as fear of unconscious bias among health care providers [11], lack of trust or confidence in healthcare providers, and frustration about finding solutions to end intimate partner violence [13].

In a review study by Mojahed et al. (2021), the prevalence of IPV in pregnancy was from 1.5 in Sweden to 66.9% in Kenya. While the most common type of violence is psychological violence, its rates vary from 1% in Sweden to 81% in South Africa. This is followed by physical violence ranging from 0.4% in Sweden to 60.6% in Uganda. According to a review, the rate of sexual violence is between 0.1 and 39.4%. In addition, the prevalence of economic violence in India is reported to be about 37% [14].

Women at greatest risk of harm from IPV are those who marry young, have male partners who use alcohol or drugs, less than a high school education, unemployed or intermittently employed, or had history of polygamy. Also, their mothers have been exposed to violence [15, 16]. Sufficient family income and marital satisfaction were also important predictors of IPV [17].

The change in childbearing patterns in recent decades has prominently caused the emergence of phenomena such as single-child families and childlessness [18].Giving importance to individual freedoms and independence reduces the tendency to have children [19]. Violence can affect reproductive health in different ways. According to a previous framework developed by the “Centers for Disease Control and Prevention” (CDC) for research on pregnancy-related violence, first, a cumulative history of lifetime abuse trauma in addition to violence occurring around the time of pregnancy, and second, “post-traumatic stress disorder” (PTSD) as a potential factor contributing to adverse birth outcomes. Therefore, based on this theoretical proposition that PTSD can be an acceptable mechanism for adverse outcomes through behavioral and neuroendocrine pathways, it is more emphasized [20]. IPV in reproductive age can lead to serious injury and death of mother and baby. Evidence shows that women are especially vulnerable to IPV during pregnancy and postpartum [21].

In a study by Kagou and Kamgno (2015) with aim of first physical violence and fertility in Cameroon, the results show that 59.1% of women in marital bonds have been victims of physical marital violence. The risk of physical violence was higher among women with 1 to 4 children and then women with five or more children compared to women without children [22]. Also, studies show that women who experienced physical IPV in their previous pregnancy may have more miscarriages [23].

The results of some other studies have also shown that prevention in fertility can help reduce the occurrence of physical IPV [22], while in the study of Olufunmilola et al. (2016), the results showed that 37% of women who experienced spousal violence moderately or strongly justified, they are likely to have more children. They have the least chance of using contraceptive methods and have the least desire to have more children [24].

On the other hand, in the systematic review conducted by Sharifi et al., the results showed that the possibility of violence has increased in women who have difficulty conceiving [25]. In Henriksen et al.‘s study, it was also pointed out that primiparous women who reported previous or recent sexual violence, compared to women who were not sexually abused, had a reduced chance of waiting for a baby to be born [26]. While in another study, evidence showed that IPV was associated with having a large number of children [27]. Based on this, the present systematic review performed with the aim of determining the relationship between intimate partner violence, reproductive health and the outcome of pregnancy.

Materials and methods

Data sources and search strategy

Current review study performed based on terms of “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) framework [28]. Its protocol is registered on the PROSPERO website (ID: CRD42024540677). The systematic literature review was conducted using the following electronic databases to recognize published studies: Scopus, Web of Science, PubMed, Science Direct, ProQuest and Cochrane were searched using the equivalent keywords without starting time limitation, up to January 2024. Medical subject headings by Boolean operators include: “AND, OR, and NOT’, and the related keywords to find titles and abstracts were searched as follows: (fertility OR pregnancy OR antenatal OR perinatal OR pregnant OR child bearing OR child birth) AND (intimate partner violence OR domestic violence OR abuse) in the title, abstract, or keywords were used to recognize potential studies. Additional relevant studies were explored through cross-examination of lists of retrieved papers and systematic reviews. After removing duplicate articles in endnote software update 20.6 (556 articles), 1278 articles remained, that two investigators (M.A and F.S) independently examined the article title and abstract to determine their fitness for inclusion, and extracted data through full-text screening. Disparities were resolved by discussion with a third researcher. Overall, there was complete agreement between the two reviewers. Figure 1 showed a description of the search process and article selection.

Fig. 1.

PRISMA Flowchart of the study Selection

PICO components

Population: Studies on women who face intimate partner violence.

Intervention: Faced to intimate partner physical, mental, emotional or sexual violence.

Comparison: Women who have not faced violence.

Outcomes: Reproductive health and pregnancy outcomes.

Inclusion and exclusion criteria

Inclusion criteria were peer-reviewed published observational studies: including cross-sectional, surveys, longitudinal studies, and cohort studies in English language about women who face intimate partner violence. We excluded the expert opinions, commentaries, qualitative study, case reports, editorials, conference abstract, new, and book chapters.

Study selection

A total of 1834 documents were retrieved, plus 22 additional records identified through other sources. After duplicate studies were removed, 1278 documents remained. The titles and abstracts of the studies were screened according to inclusion criteria, and a total of 1184 studies were removed. After checking, 117 reports sought for retrieval, and 50 reports not retrieved.

Full texts of the 67 studies were assessed for eligibility, and 28 articles were excluded. Finally, 39 articles were reviewed (Fig. 1).

Assessment of the quality of the reviewed papers

The quality of each article was assessed using the relevant “Critical Appraisal Skills Programme” (CASP) checklist for observational studies, a score out of 12 was used (total 12 questions, question 5 and 6 consisted of two parts “a and b”) [29]. The first two questions are screening questions and can be answered quickly. There is some degree of overlap between the questions, so to check the questions, we recorded “yes”, “no” or “can’t say” (Table 1).

Table 1.

Characteristics of thirty-nine included studies focused on the relationship between IPV, reproductive health and pregnancy outcome

Authors/Year/Country	Scope related to IPV	Study method	Participants	Sample Size	Instrument	Quality Score*	Outcomes ) association with IPV)
Dhar et al. (2018), India [30]	RMH	Cross-sectional	Mothers of children 0– 2-year-old	13,863 W	Self-reported lifetime experiences of IPV	Y: 10 C:2	Elevation risk of miscarriage, stillbirth, and maternal health.
O’Hara et al. (2013), Jordan [31]	CU	Descriptive\secondary analysis of survey	aged 15–49 years	3434 W	DVM	Y: 11 C:1	Severe physical IPV was less likely to CU. Individuals experiencing sexual IPV showed a higher tendency to utilize UC. Emotional and milder forms of physical IPV were not associated with CU
Forrest et al. (2018), India [32]	CU	longitudinal follow-up survey	Fertility age (15–49 years)	2834 W	DVM	Y: 9 C:2 N:1	IPV no effect on sterilization.
Clark et al. (2008), Jordan [33]	Avoid Pregnancy	Survey	aged 15–49, literate	517 W	Self-administered Q. based on the WHO. Women’s Health and Life Events Q.	Y: 10 C:2	In-creased risk of experiencing interference with their attempts to avoid pregnancy.
Emenike et al. (2008), Kenya [34]	RH	Based on Survey	15–49 years of age, household	4312 W	Comprehensive Q. covering demographic and health issues, DVM	Y: 8 C:4	Negative RH outcomes such as terminated pregnancies and infant mortality. Use of FP methods and high fertility.
Deyessa and Argaw (2018), Ethiopia [35]	UN for CU	Cross-sectional cohort study	Reproductive age	2810 W	Women’s Q. interviewed	Y: 11 C:1	UN for CU
Liu et al. (2016), Texas [36]	FC and PO	prospective longitudinal study	Reproductive age	300 W	Interview, FC Q. Women’s Q.	Y: 11 N:1	Increased risk for UP and adverse PO of premature birth and miscarriage.
Ahinkorah et al. (2020), sub-Saharan Africa [37]	UN for CU	Secondary datasets analysis	Women in sexual unions	101,968 W	Self-reported of sexual violence	Y: 11 N:1	Association between sexual violence and UN for CU
Cwikel et al. (2003), Israel [27]	Physical and psychosocial health	part of survey	Age 22 to 75 year	202 W	The Q. based on the Hebrew version of the Commonwealth Fund’s Survey of Women’s Health	Y: 12	Positive correlation between the number of children and the level of IPV. associated with a large number of children. Level of IPV decreases during pregnancy.
McCarraher et al. (2005), Bolivia [38]	birth predictedness during pregnancy	A longitudinal study	participated in the Survey (DHS) and lived in El Alto and La Paz Bolivia	1308 W	Two questions to assess violence during the last pregnancy	Y: 10 C:2	No relationship found between birth predictedness and IPV in pregnancy
Titilayo and Palamuleni (2015), Malawi [39]	UF	Survey	Childbearing in last five years	4,137 W	A series of questions that askes about IPV	Y: 11 N:1	IPV a predictor of UF. UF is higher among women with IPV.
Pearson et al. (2017), Bangladesh [40]	Reproductive autonomy and RH	cross-sectional a secondary analysis	Aged 18–49 years, Seeking abortion care	457 W	Standard questions from the Bangladesh Demographic and Health Survey based on Conflict Tactics Scales	Y: 11 C:1	Associated with additional constraints on reproductive autonomy
Dadras et al. (2022), Afghanistan [41]	UN for FP	Data from Survey	aged 18–49 years	21,361 W	Standard DHS Q.	Y: 12	UN for FP documented in less than 1/3 of People.
Kupoluyi (2020), Nigeria [42]	CU	Used Survey	Rural and urban households.	1341 W	Reproductive calendar on CU, DVM	Y: 12	More likely to have discontinued CU
Oni et al. (2021), Nigeria [43]	FP	From Survey	at least one birth	4,650 C	DVM	Y: 11 C:1	C with no IPV had a 13% higher likelihood of FP.
Muluneh et al. (2023), Sub-Saharan Africa [44]	CU	Demographic and Health Surveys	Ever married, reproductive age from six countries	30,715 W	DVM	Y: 11 C:1	Physical violence was negatively associated with not CU.
Silverman et al. (2020), Nigeria [45]	FP	Cross-sectional from survey	Married adolescents’ girls in the Dosso region of Niger	1072 W	DVM	Y: 12	Physical IPV and reproductive coercion were associated with covert FP.
Stephenson et al. (2008), India [46]	CU and UP	Data from Survey	Women residing in households.	89,199 W	Household Q., a village Q., CU and UP Q.	Y: 10 C:2	Physical violence less likely to adopt CU and more likely to experience an UP.
Tiruye et al.(2020), Ethiopia [47]	UP	Cross-sectional from survey	15–49 years old	5860 W	Q. of the EDHS, the reproductive intentions of the women for each pregnancy and/or birth within the past 5 years, questions based on the Conflict Tactic Scales of Straus.	Y: 12	Significant association observed with UP . No association between UP and experiencing a single act of partner controlling behavior
Cohort Grundy etal(2022), Malawi [48]	CU	Cohort	Women aged 15–24	1000 W	Conflict Tactics Scale	Y: 12	No key operative of CU.
MacQuarrie and Mallick (2021), Kenya [49]	CU	Cross sectional, Survey	Married women With CU	1,437 W	WHO guidelines on the ethical conduct of DV, conflict tactics scales	Y: 12	Emotional violence positively associated with higher odds of discontinuation while still in need (DWSIN). Sexual violence less related with higher odds of DWSIN. physical violence no related with DWSIN.
Raifman et al. (2021), Nepal [50]	Fertility	Cohort	Newly married women	200 W	World Health Organization guidelines, multi-country search measure of violence	Y: 10 C:2	IPV were more than 2 times higher for participants who became pregnant and birth than for those who did not.
Gee et al. (2009),United State [51]	FC	survey	women at the Philadelphia centers of Planned Parenthood	1463 W	a researcher made Q. CDC’s Behavioral Risk Factor Surveillance System DVM.	Y: 12	Partner unwillingness to CU, partner desirous of conception and subjects expressing inability to afford contraception positively associated with IPV. CU more difficult to navigate for women experiencing IPV.
, Pallitto and O’Campo (2004), Colombia [52]	UP	Cohort	Birth in the last five years or were pregnant.	3,431 W	Women’s Q about women’s reproductive and sexual history	Y: 10 C:1 N:1	In physically or sexually abused women, UP increased. history of parental violence and forced sex by a non-partner was positively associated with UP. A significant relationship between UP and IPV.
Muluneh et al. (2023), Eastern Sub-Saharan Africa [53]	UP	cohort	pregnancy in the previous 5 years	33,640 W	DVM	Y: 11 C:1	Women who had more than five live children had an increased risk of UP.
Martin-de-Las-Heras et al. (2015), Spain [54]	UP	Population-based study	admitted for delivery or early Symptoms of delivery.	779 W	Index of Spouse Abuse (ISA). Pregnancy Intendedness	Y: 12	Unintended pregnancy was associated with: physical and/or emotional IPV. emotional IPV around pregnancy was significantly associated with UP. Report of UP related to emotional IPV.
Ogunjuyigbe et al. (2010), Nigeria [55]	UN for Contraception	Secondary data from a survey	One household in a housing (male or female), aged 18 years	………	…………….	Y: 6 C:4 N:2	DV was not a strong factor influencing CU and UN in the area as spousal opposition was not cited as their reason by any of the women who were not CU.
Paul (2022), India [56]	CU	Large-scale sample survey	Married women of reproductive age, currently non-pregnant.	58,891 W	DVM	Y: 12	Modern CU was lower among women who experienced IPV. women who experienced any IPV and their husband’s controlling attitudes were 12% less likely to modern CU and 11% more likely to undergo sterilization.
Silverman (2023), Niger [57]	CU	Cluster-randomized trial	Married adolescent girls and their husbands	1072 W And 1080 M	Health Surveys DVM	Y: 10 C:1 N:1	Intervention group were less likely to report past-year IPV.
Kuhlmann et al. (2019), Honduras [58]	CU	Cross-sectional	aged 18–30 years, with no prior sterilization, and with no current pregnancy or plans to conceive.	577 C	Demographic data and reports of IPV were recorded through the survey responses of the wives	Y: 11 C:1	IPV related to CU without spouse informing , possibly to redress the CU often exerted by IPV.
Acharya et al. (2019), Nepal [59]	CU	A cross-sectional analysis	Among ever-married women of reproductive age	3562 W	DVM	Y: 11 C:1	Associated with sterilization
Silverman et al. (2007), Bangladesh [60]	UP, miscarriage, induced abortion, and stillbirth	Cross-sectional, data from Survey	Married ages 13–40 years old	2677 W	The BDHS Q, women’s Q for RH outcomes	Y: 12	More likely to report both UP and a pregnancy loss in the form of miscarriage, induced abortion, or stillbirth. miscarriage was more likely among victimized women. A nonsignificant trend was detected for increased risk of induced abortion. stillbirth was unrelated to violence from husbands.
Kuhlmann et al. (2019), Honduras [58]	Pregnancy Intention and CU	Secondary data	were married/living with partner, and had least one living child under 5 years	6629 W	DVM	Y: 11 C:1	IPV were more likely to have ever CU yet more likely to report UP.
Tiruye (2020), Ethiopia [61]	CU and Women’s Autonomy	Cross sectional national survey	become pregnant five years	2969 W	IPV Q.	Y: 12	UP positively associated with reporting sexual IPV, emotional IPV, IPV, and multiple partners controlling behavior. IPV (as a composite of all four forms), physical IPV, and partner control (single act) were not associated with UP.
Deogan et al. (2022), Sweden [62]	Unwanted Child	From the randomized population-based survey	Aged between 16 and 84 years	14,537 W and M	Researcher made Q.	Y: 12	Previous experience of induced abortion, sexual violence and threat from a partner were significantly associated with UP.
Alio et al. (2009), Sub-Saharan Africa [63]	CU	Surveys	Fertility age	24 311 W	DVM	Y: 9 C:2 N:1	IPV associated with increased CU. modern CU more commonly than traditional and folkloric methods.
Pallitto and O’Campo (2005), Colombia [64]	UP	from a Survey	pregnant in the 5 years prior to the survey or currently pregnant	3431 W	Researcher made Q.	Y: 11 C:1	Associated with UP.
Shittu et al. (2022), Nigeria [65]	Birth Spacing	Secondary data from Survey	aged 15 to 49 with a live birth	41,821 W	Self-administered structured Q.	Y: 10 C:2	IPV influenced child spacing.
Ghahfarokhi (2023), Afghanistan [66]	Fertility	Cohort	Married 15 to 49 years old	28,671 W	Series of questions related to IPV	Y: 11 C:1	IPV may affect reproductive outcomes, parity progression ratio, childbirth intervals, and TFR. Women with IPV reproduce more quickly. TFR is slightly lower among women who have experienced IPV.

y yes, N no, C Can not tell, W Women, M Men, C Couple. Q Questionnaire, RMH Reproductive and Maternal health, CU Contraception Use, RH Reproductive Health, UN Unmet Need, PO Pregnancy Outcomes, UF Unwanted Fertility, FC Fertility Control, DV Domestic Violence, DVM Domestic Violence Module, TFR Total fertility rate

Data extraction

For each study, the following data extracted according to a predefined checklist including first author, year, country, aim, study method, participants, sample size, instrument, quality score and outcomes. Data were independently assessed by two reviewers and the summarized characteristics of the included studies are shown in Table 1.

Results

Overview of studies

Out of 1834 documents reviewed, a total of 39 studies [27, 30–67], that considered the women with a history of intimate partner violence or domestic violence and reproductive health and pregnancy outcome were included in this review (Fig. 1). About 50% of the articles were related to the last five years [37, 41–45, 47–50, 53, 56–59, 61, 62, 65, 66].

Studies with different methods of observational studies, including cross-sectional [30, 35, 45, 47, 49, 59, 61, 67], surveys [27, 31–34, 37, 39, 42–44, 46, 51, 56, 58, 63–65], longitudinal studies [36, 38], cohort studies [48, 50, 52, 53, 66], population-based study [54], randomized trial [57] and randomized population-based [62] were reviewed. Regarding the quality score of the articles, about 90% of them had a quality score above 75% [27, 30–32, 35–54, 56–62, 64–67]. Some studies were obtained from secondary analysis of publications [27, 31–34, 37, 39, 45–47, 49, 54, 55, 58, 61, 62, 65, 67].

Main results

Relationship between IPV and reproductive health

Number of children and childbirth intervals

A study showed that there is a positive correlation between the large number of children and the level of IPV [27]. IPV may affect reproductive outcomes, parity progression ratio, childbirth intervals, and total fertility rate (TFR). Women who have experienced IPV appear to reproduce more quickly and tend to start childbearing more quickly and continue to do so than those who do not [66]. Additionally, intimate partners’ violence significantly influenced child spacing [65]. TFR is slightly lower among women who have experienced IPV compared to those who have not experienced IPV [66].

Unwanted and Unintended pregnancy

Spousal violence is a predictor of unwanted fertility [39], and increased risk for unintended pregnancy [36]. Women with physical violence experience less likely to adopt contraception and more likely to experience an unwanted pregnancy [46]. Some women exposed to intimate partner violence were more likely to have ever used contraception yet more likely to report an unwanted pregnancy [52, 58, 64]. In addition, previous experience of induced abortion, sexual violence and threat from a partner were significantly associated with unwanted childbirth [62].

In another study, unintended pregnancy was significantly associated with physical and/or emotional IPV [54]. In another cross sectional study by Tiruyl et al. about the mediation effect of contraceptive use and women’s autonomy on the relationship between intimate partner violence and unintended pregnancy in Ethiopia, unintended pregnancy was positively associated with reporting sexual IPV, emotional IPV, and partners controlling behavior, but IPV (as a composite of all four forms), physical IPV, and partner control (single act), were not significantly associated with unintended pregnancy [61]. It should be noted that in another study no association was seen between unintended pregnancy and experiencing a single act of partner controlling behavior [47].

Contraception use

In another study partner unwillingness to use birth control, partner desirous of conception, partner creating difficulty for subject’s use of birth control, and subjects expressing inability to afford contraception, positively was associated with IPV. Each additional pregnancy was associated with 10% greater odds of IPV. Contraception was more difficult to navigate for women experiencing IPV [51]. Couples with no IPV had a 13% higher likelihood of planning their fertility [43].

In other study, women with experience of IPV had negative use of family planning methods and they have a high fertility experience [34]. Even, there was an risk of IPV experiencing interference with their attempts to avoid pregnancy [33]. Women with experience of IPV more likely to had discontinued contraceptive use although they were still at risk of becoming pregnant than those who had not experienced IPV [42]. In other research, women who reported IPV from their husbands might be more likely to used contraceptives without informing their husbands, possibly to redressed the reproductive control often exerted by abusive male partners [67].

Conversely, in other studies domestic violence was not a strong factor influencing contraceptive use and unmet need in the area as spousal opposition was not cited as their reason by any of the women who were not using contraceptives [48, 55].

Use of modern contraceptives was significantly lower among women who experienced IPV. women who experienced any IPV and their husband’s controlling attitudes were 12% less likely to use modern contraceptives and 11% confidence were more likely to undergo sterilization [56], but in the African setting, IPV was associated with increased contraception use, and modern contraception was used more commonly than traditional and folkloric methods [63]. Also married adolescents’ on modern contraceptive use were less likely to report past-year IPV [57]. Although in a study in married women in Nepal IPV was associated with sterilization [59], but in other study violence had no effect on sterilization among women [32].

Contraception use and types of IPV

About the types of IPV, Although women with severe physical IPV was less likely to use contraception [31], but physical IPV and reproductive coercion were associated with covert family planning use [45]. In other study, women with physical violence was less likely to adopt contraception and more likely to experience an unwanted pregnancy [46]. In contrast,, in some studies physical violence was negatively associated with not using any contraceptive method among married women in Eastern Sub-Saharan Africa countries [44], and physical violence wasn’t associated with higher odds discontinuation contraception while still in need [49].

Although in a study, emotional violence positively associated with higher odds discontinuation contraception while still in need [49], but in other study emotional and less severe physical IPV not related to contraception use [31].

Additionally, women with sexual IPV were more likely to use contraception [31]; however, in other study, sexual violence was weakly associated with higher odds of discontinuation contraception [49].

Unmet need for contraception use

Some women exposed to intimate partner violence were more likely to have ever used contraception yet more likely to report an unwanted pregnancy [58, 64]. Additionally, association between IPV and unmet need for contraception was documented [35, 37, 41]. But in other study domestic violence was not a strong factor influencing contraceptive use and unmet need in the area as spousal opposition was not cited as their reason by any of the women who were not using contraceptives [55]. Association between IPV and additional constraints on reproductive autonomy was reported [45].

Relationship between IPV and pregnancy outcomes

Maternal health

While the increased risk of maternal health complications was reported in pregnant women with IPV in a study [30], in other study, no relationship was found between birth prediction and violence during their pregnancy [38].

Pregnancy

Although based on findings of a study level of IPV decreases during pregnancy [27], in other study any intimate partner violence were more than two times higher for participants who became pregnant and gave birth than for those who did not [50]. This despite the fact that based on other study findings no relationship was found between birth predicted ness and violence during their pregnancy [38].

Pregnancy outcomes

Intimate partners’ violence significantly increased stillbirth, miscarriage and risk of adverse pregnancy outcomes of premature birth [30, 36]. Also, based on a study miscarriage was more likely among victimized violence women, and a nonsignificant trend was detected for increased risk of induced abortion [60]. In another study negative reproductive health outcomes about violence spouse was terminated pregnancies and infant mortality [34]. Women with an experience of IPV more likely to report both unwanted pregnancy and a pregnancy loss in the form of miscarriage, induced abortion, or stillbirth [60]. Women who experienced IPV had negative reproductive health outcomes such as pregnancy termination, infant mortality, and the use of family planning methods, and their fertility rate was high [34].

Discussion

Present systematic review was conducted with the aim of determining the relationship between including IPV, reproductive health and pregnancy outcome.

Number of children and childbirth intervals

Although a study found level of IPV decreases during pregnancy [27], another study reported that any form of intimate partner violence was more than two times higher for participants who became pregnant and gave birth than for those who did not [50]. There is a positive correlation between the large number of children and the level of IPV [27]. IPV may affect reproductive outcomes, parity progression ratio, childbirth intervals, and TFR. Women who have experienced IPV appear to reproduce more quickly and tend to start childbearing more quickly and continue to do so than those who do not [66]. Additionally, intimate partners’ violence significantly influenced child spacing [65]. TFR is slightly lower among women who have experienced IPV compared to those who have not experienced IPV [66]. In study by Sharifi et al. (2022) results of meta-analysis showed that the prevalence of domestic violence in infertile women stood at 47.163% [25]. Of course, this issue should not be overlooked that the reasons for a man’s violence can be his desire to have more children or children or a specific gender, so he commits violence against his wife, which needs more studies.

It seems natural that the level of reported violence decreases during pregnancy due to women’s vulnerability. However, another study presents conflicting results that may be attributed to postpartum violence. In the postpartum period, women are faced with postpartum depression to some extent [68]. Identifying and supporting women experiencing IPV is critical, which requires incorporating IPV screening into prenatal care and reproductive health [69].‏ The observed difference in the findings of this study could be due to the way IPV screening is conducted in the studies, which emphasizes the need to modify IPV screening programs in reproductive health care. Also, understanding the experience of managing domestic violence among pregnant women is essential to design evidence-based violence prevention programs, which enable supportive healthcare and social systems to encourage abused mothers to use more effective strategies and seeking help to overcome domestic violence [70].

As can be seen from the results, acts of violence increase in families with more children, which, as mentioned earlier, can be related to the socio-economic status and low level of literacy in these families [3, 4].

Un wanted and unintended pregnancy

Based on findings, spousal violence is a predictor of unwanted fertility [39], and increased risk for unintended pregnancy [36]. Unintended pregnancy was significantly associated with physical and/or emotional and/or sexual IPV [54, 61, 62]. However, another study no association was seen between unintended pregnancy and experiencing a single act of partner controlling behavior [47]. Although in a study, emotional violence positively associated with higher odds discontinuation contraception while still in need [49], but another study found no relation between emotional and less severe physical IPV and contraception use [31]. Additionally, women who experienced sexual IPV were more likely to use contraception [31], but another study found that sexual violence was weakly associated with higher odds of discontinuation contraception [49].

It should be noted that marital behaviors, childbearing control, use or non-use of contraceptive methods are influenced by a range of cultural, social and psychological factors. The mentioned studies are related to different societies in terms of geographical location and economic and social status. Interestingly, opposite results have been obtained in countries with similar conditions [39, 47]. Mechanisms behind unintended, unplanned, unwanted or mistimed pregnancies are complex [62]. In some societies and cultures, a man’s violence towards his wife is accepted and sometimes even considered a source of pride for women, which naturally affects marital relations and child bearing [71, 72]. On the other hand, in some cases, violence is accompanied by having sex with force and coercion, which naturally will not be possible to conceive or prevent pregnancy [67]. Also, violence can make a woman feel helpless, hopeless and depressed, which will be the result of not paying attention to various things in life, including planning for having children. Therefore, in fact, the relationship between violence and unwanted pregnancy is a complex issue with different cultural and psychological reasons. The study revealed a significant variation in the connection between unintended pregnancy and intimate partner violence across different countries. This disparity may stem from differences in factors such as women’s empowerment, access to contraceptive methods, and conflict levels in those countries. In addition, it should be noted that several factors influencing pregnancy intention, such as access to contraceptive methods, societal norms related to ideal family size, exposure to situations of conflict and displacement, and access to abortion, vary significantly across different countries [73].

Contraception use

Based on a research findings partner unwillingness to use birth control, partner desirous of conception, partner creating difficulty for subject’s use of birth control, and subjects expressing inability to afford contraception, positively was associated with IPV [51].

In one study, women with experience of IPV more likely to have discontinued contraceptive use although they are still at risk of becoming pregnant than those who have not experienced IPV [42]. Experience of IPV had negative effect on use of family planning methods and women who experienced IPV had a higher fertility rate [34]. On the other hand, women with the intention of having children may try to stop using contraceptive methods because they think having a child is a way to change their current life situation and save them from their husband’s violence.

In another research, women who reported IPV from their husbands might be more likely to use contraceptives without informing their husbands [67]. These results imply that violence enables some men to resolve disagreements over the use of contraception by imposing their fertility preferences on their partners [32]. Conversely, in other studies domestic violence was not a strong factor influencing contraceptive use and unmet need [48, 55]. Regarding the types of IPV, although women who experienced severe physical IPV were less likely to use contraception [31], physical IPV and reproductive coercion were associated with covert family planning use [45].Another even in other study found that women experiencing physical violence were less likely to adopt contraception and more likely to experience an unwanted pregnancy [46].

These findings should also be interpreted with caution. Because, on the one hand, women’s turning away from using contraceptive methods can be the result of a person’s feeling of disgust and humiliation as a result of violence by his wife. Additionally, women’s feeling of inadequacy and low self-efficacy in controlling life affairs, including issues related to fertility and motherhood can be counted among other causes [74]. As Bigizadeh et al.‘s study showed, self-efficacy and self-esteem were at a low level in women who were subjected to domestic violence [75].

In the case of women under violence who secretly use contraceptive methods [45], it can be said that this is a result of dissatisfaction with their current life and as a result of their unwillingness to have children in order to create easier conditions for divorce and leaving the current marital relationship. Couples’ expectations from the institution of marriage are based on couple interactions to help individual growth and development, have children and social development of children [76]. There is a positive relationship between the level of women’s violence and marital dissatisfaction, and there is a significant and negative relationship between women’s sense of self-worth and family violence [77].

Use of modern contraceptives was significantly lower among women who experienced IPV [56], but intimate partner violence appears to be associated with increased contraception use in the African setting, and modern contraception is used more commonly than traditional and folkloric methods [63].

As expected, violence can be more prevalent in lower economic and social levels and people with low literacy levels, whose access to modern contraceptive methods is more limited [3, 4]. Regarding the contradictory results on the African continent, there is a need for further investigation to comment, one of the possible causes can be attributed to the promotion of modern contraceptive programs by transnational organizations, considering the high population growth in this continent.

Unmet need for contraception use

Association between IPV and unmet need for contraception was documented [35, 37, 41], but in other study unmet need in the area as spousal opposition was not cited as their reason by any of the women who were not using contraceptives [55]. Despite this, association between IPV and additional constraints on reproductive autonomy was reported [45, 47]. Women’s autonomy, had a significant partial mediation effect in the relationships between some forms of IPV and unintended pregnancy [61].

It seems reasonable that the husband’s coercion, especially in cases with violence, is one of the reasons for not being able to use contraceptives despite the desire to do so. Regarding the contradictory results, it is possible to consider the methodological flaws of some studies and the caution of women in stating the facts in their statements.

Pregnancy outcomes

Intimate partners’ violence significantly increased stillbirth, miscarriage and risk of adverse pregnancy outcomes of premature birth [30, 36]. Also, based on a study miscarriage was more likely among victimized violence women, and a non-significant trend was detected for increased risk of induced abortion [60]. In another study negative reproductive health outcomes about violence spouse was terminated pregnancies and infant mortality [34]. Women who experienced IPV were more likely to report both unwanted pregnancy and a pregnancy loss in the form of miscarriage, induced abortion, or stillbirth [60].

It should be noted that one of the consequences of violence during pregnancy is damage to both the mother and the fetus. This can lead to an increase in spontaneous abortions and stillbirths and other negative consequences during pregnancy. On the other hand, women subjected to violence during pregnancy may not be in proper nutritional conditions, may not have good access to prenatal care and endure more stress [3, 4], which will cause severe complications during pregnancy and after for the mother and child.

In women under violence, due to frustration and rejection from their husbands, as well as the advice of influential people around them, the tendency to induce abortion can increase. In addition, according to the mentioned results, unwanted pregnancy is more prevalent among women experiencing higher levels of violence, which may increase the cases of induced abortion [36, 39, 60]. Finally, empowerment of family and society, along with comprehensive sex education and access to sexual and reproductive health and right, is critical strategy of women’s empowerment in health. This can enhance their health knowledge and related behaviors in face of the violence [78–81]. The results of this research highlight the need to enhance the empowerment of women and families in different areas such as traditional beliefs, attitudes, and practices. This process includes evaluating and reinforcing interdisciplinary cooperation among stakeholders, such as policymakers, service providers, administrative staff, and community leaders, with a specific focus on engaging men in the process.

Conclusion

According to the results of this study, domestic violence can affect various aspects related to women’s reproductive health, include in the desire to have children, experiences unwanted pregnancy, contraceptives use and overall women’s health, especially during pregnancy. The use or non-use of contraceptives is influenced by numerous social, cultural and psychological factors. Additionally, contradictory results were observed in the performance of women subjected to violence regarding their control over childbearing, which may be attributed to cultural factors, family pressure, literacy level, and socio-economic status, and even the relationship between acts of violence to the desire to have children.

The study highlights that women subjected to violence may face an increased risk of pregnancy complications, abortion, stillbirth and infant mortality. Furthermore, the incidence of induced abortion among women experiencing violence can be increased. Therefore, addressing violence against women by the husband should be given more attention and solutions should be considered at the social and individual level. Empowering family and society is crucial factor in prevention and protection against such violence.

Based on the findings of this study, it is recommended to increase society’s awareness about the consequences and adverse outcomes of IPV on reproductive health. This requires the cooperation of all beneficiaries in the society. The health providers have a special place. They play an important role in gathering information, screening for IPV, and providing counseling and education to prevent IPV and its consequences. Also, they require the support of other stakeholders, such as policymakers and community leaders, to implement appropriate laws and provide the context for community education.

Limitation and strength of the study

The studies included in this systematic review were conducted across different countries, mainly in Asia and Africa, which may limit the generalizability of the findings to other regions and populations. A major limitation of this review was the restricted access to certain databases, as well as the unavailability of full texts for some potentially relevant articles. Additionally, some online resources lacked advanced search features, which may have prevented the inclusion of all relevant studies. Variations in study design, sample size, and data collection methods across the included studies may have contributed to heterogeneity in the results. Furthermore, differences in cultural, social, and healthcare contexts across countries may have influenced both the prevalence and reporting of intimate partner violence, as well as its impact on reproductive health and pregnancy outcomes.

Despite these limitations, this review has several strengths. Most of the included studies were of high methodological quality, enhancing the reliability of the evidence. The systematic approach allowed for a comprehensive synthesis of diverse studies, providing valuable insights into the complex relationship between intimate partner violence and reproductive health outcomes. The inclusion of studies using different research methods and settings offers a broad understanding of the issue across multiple contexts.

Future research should prioritize large-scale, multi-center, population-based studies using standardized and validated data collection tools to better evaluate the impact of intimate partner violence on reproductive health and pregnancy outcomes. Such studies will be instrumental in developing effective prevention strategies, interventions, and policies tailored to diverse populations and cultural settings.

Abbreviations

IPV

Intimate partner violence

PTSD

Post-traumatic stress disorder

RMH

Reproductive and Maternal health

CU

Contraception Use

RH

Reproductive Health

UN

Unmet Need

PO

Pregnancy Outcomes

UF

Unwanted Fertility

FC

Fertility Control

DV

Domestic Violence

DVM

Domestic Violence Module

TFR

Total fertility rate

DWSIN

Discontinuation while still in need

WHO

World health organization

Q

Questionnaire

W

Women

M

Men

C

Couple

Y

yes

N

no

C

Can not tell

Authors’ contributions

“FS, MA, MM, and NS designed the study. M.A and F.S conducted the search and extracted data. FS, MA, MM, AA, AS, and NS, and NS wrote the manuscript text. FS, MA and FG prepared figure and table. All authors revised the manuscript and approved final version of the manuscript.”

Funding

This study was financially supported by the Vice Chancellor for Research, Shahrekord University of Medical Sciences, Shahrekord, Iran with Grant number: 6730.

Data availability

The data of current study is available from the corresponding author.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Shahrekord University of Medical Sciences (ID: IR.SKUMS.REC.1401.201). Its protocol was registered on the PROSPERO website (ID: CRD42024540677).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.