Examining Family Violence and Reproductive Autonomy Among Arab American Women

Abstract

Background:

Women who experience violence from an intimate partner are at risk of experiencing lower levels of reproductive autonomy. Among Arab American women, cases of intimate partner violence may also involve other family members, including in-laws or natal family, a phenomenon also known as family violence. This study examined the role of family violence on reproductive autonomy among Arab American women.

Methods:

Data were collected from a convenience sample (N = 99) of self-identified Arab American women between 18 and 65 years in Dearborn, Michigan, through a cross-sectional survey of self-reported experiences with family violence and reproductive autonomy. Analyses included univariate statistics on sociodemographic characteristics and prevalence of family violence, a psychometric analysis of a multidimensional scale of reproductive autonomy, and adjusted linear regressions to assess how sociodemographic characteristics and family violence were associated with reproductive autonomy.

Results:

Nearly 60% of the sample had ever experienced family violence. Among women who had ever had sex (N = 74), higher educational attainment was positively associated with communication and freedom from coercion, and receipt of public assistance was negatively associated with communication. Several types of family violence were negatively associated with the communication and freedom from coercion subscales from the reproductive autonomy measure.

Conclusion:

This study demonstrated that sociodemographic factors and family violence are both associated with reproductive autonomy among Arab American women. More research is needed to address family violence and reproductive autonomy in this community and examine how these experiences shape the reproductive health of Arab American women.

Background

Arab Americans trace their roots to 22 different Arabic-speaking countries in the Middle East, North Africa, and sub-Saharan Africa^a,1–3 and make up an estimated 3.5 million of the U.S. population.⁴ Arab American women indicate that family violence, which refers to any emotional, physical, and/or sexual abuse or battery of an adult woman from a married or unmarried partner or other family members,⁵ is a critical concern within their community.⁶ Family violence is shown to occur concurrently with reproductive coercion (i.e., behaviors that are used to exert power over another’s reproductive intentions and decisions) and be associated with unintended pregnancy, abortion, sexually transmitted infections, poor pregnancy outcomes, and psychological trauma.^7–10 No studies have explored how survivors of family violence within the Arab American community navigate reproductive autonomy or their ability to make autonomous decisions regarding their reproductive health (e.g., contraception, pregnancy, and childbearing decision).¹¹ This study aims to address this gap by assessing the role of family violence on reproductive autonomy among Arab American women in Dearborn, Michigan.

Family violence among Arab Americans has been reported to be prevalent, particularly in the communities of southeast Michigan. One study of Iraqi immigrant women in Metro Detroit reported that 93% of women had experienced controlling behaviors (i.e., been shouted or screamed at, put down in front of others, threatened, shouting, or threatening of children), and nearly 80% had experienced threatening behaviors and physical violence from a partner.¹² More recently, a study of intimate partner violence victimization of Arab American young adults found that 76% had experienced psychological victimization and nearly half had experienced physical violence.¹³ The global literature on Arab women’s experiences with violence also reports that among Jordanian women, members of the extended family may also be involved in violent disputes between intimate partners.¹⁴ Physical, psychological, and sexual violence have also been reported among pregnant women in Jordan.^15,16 Given the shared cultural norms between Arab families overseas and the in United States, as well as increased risk of violence following migration,^17–19 Arab women within the United States may also be at risk of experiencing family violence within the context of their intimate relationships.^14,20

Women who have experienced family violence are more likely to experience behaviors from a partner that are indicative of reproductive coercion, such as birth control sabotage (intentional destruction of a woman’s chosen method of contraception), pregnancy pressure (behaviors to coerce pregnancy against one’s wishes), and pregnancy coercion (threats to the direct the outcome of a pregnancy).^21,22 Upadhyay and colleagues were among the first to develop a comprehensive measure that assesses how these behaviors shape interpersonal relationships and the reproductive intentions of women.¹¹ In order to be inclusive of individuals of various racial, ethnic, geographic, and socioeconomic backgrounds, the measure was tested in English and Spanish across 13 family planning clinics and 6 abortion facilities^b in urban and rural settings in the United States.¹¹ Psychometric analysis of the scale resulted in a 14-item measure that assessed reproductive autonomy across three domains including communication, freedom from coercion, and decision-making power (see Fig. 1 for definitions of each construct). The reproductive autonomy scale has not been tested among Arab American women; however, because the measure accounts for family involvement (in-laws, natal family, and other extended family members) in reproductive coercive behaviors,¹¹ and has been adapted for other immigrant communities, it can serve as a reliable measure for assessing reproductive autonomy within the Arab American community.

FIG. 1.

The large external rectangle represents the concept of reproductive autonomy. The blue ovals contain the name of the three constructs/subscales measured in the reproductive autonomy scale. The rectangles attached to each blue oval represent the corresponding definition of each of the constructs/subscales from the reproductive autonomy scale.

Understanding the consequences of family violence on reproductive health and how these issues may uniquely affect the Arab American community, in 2016, the University of Michigan built a community–university partnership with the Arab Community Center for Economic and Social Services (ACCESS) in Dearborn, Michigan. This partnership resulted in a mixed methods pilot study of family violence, reproductive autonomy, and various reproductive health outcomes among Arab American. The study was conducted in Dearborn, Michigan, which has a 55% Arab population and has the largest concentration of Arabs outside of the Middle East. This study focuses on the quantitative phase of the study and addresses the following research questions:

• 1.What is the prevalence of family violence among Arab Americans in Dearborn, Michigan?
• 2.Can an existing multidimensional and multilingual scale that assesses reproductive autonomy in other racial, ethnic, and immigrant populations be used to examine reproductive autonomy among Arab American women?
• 3.What sociodemographic characteristics are associated with reproductive autonomy among Arab American women?
• 4.Is family violence associated with reproductive autonomy among Arab American women?

Methods

Sample

Self-identifying Arab American women^c between the ages of 18 and 65 years were eligible to participate in the study (N = 99). A case manager from ACCESS recruited a convenience sample from ACCESS clinics and ACCESS-sponsored community events. The sample was 95% Muslim, and the response rate for the survey was 66%.

Data collection

Data collection occurred from April to August 2018 at three ACCESS clinics and ACCESS-sponsored community events. Surveys were completed electronically on an iPad, lasted 30 minutes, and were available in English and Arabic. Respondents could take the survey on their own or with the case manager. Community partners felt that offering the choice to administer the survey with the case manager would elicit honest responses. All surveys were conducted in a private area at the ACCESS clinics or events. Respondents could skip questions or terminate their participation at any point of the study. Participants were given $30 cash incentives. All study procedures were approved by the Institutional Review Board at the University of Michigan–Ann Arbor and the Community Health and Research Center at ACCESS.

Measures

Dependent variables

Reproductive autonomy was assessed among individuals who had ever had sex (N = 74) and in respect to one’s most recent sexual partner. The communication subscale consisted of five items that assessed the degree to which one could communicate with their partner about reproductive decisions (1 = strongly disagree to 4 = strongly agree). The freedom from coercion subscale included five items that assessed the degree to which one’s partner or someone else (i.e., parents, in-laws, or extended family members) practiced various elements of coercion (1 = strongly disagree to 4 = strongly agree). Items from the freedom from coercion subscale were reverse coded such that the highest value reflected the highest level of reproductive autonomy. The decision-making subscale consisted of four items that asked which partner had the final say in different reproductive situations with response choices of me, my sexual partner, both me and my sexual partner equally, or someone else (i.e., my parents, in-laws, or extended family member[s]). Mean scores were calculated for each subscale; higher scores on each subscale represented higher levels of reproductive autonomy.

Independent variables

Four measures that were used to assess family violence were derived from the second and third waves of the National Longitudinal Study of Adolescent to Adult Health (Add Health).²³ Four additional items were added to reflect unique experiences that may occur within the Arab American community based on the recommendations from ACCESS. Items derived from Add Health included if a partner or someone else had disrespected (e.g., swore at them, called them names, insulted, or treated disrespectfully), threatened, physically hurt (pushed, hit, or threw something at you that could hurt), or had forced sex with them in the past 12 months (0 = “never,” 1 = “1 time,” 2 = “2 times,” 3 = “3–5 times,” 4 = “6–10 times,” 5 = “more than 10 times,” and 6 = “not in the past year, but it did happen before). Responses were collapsed into a binary measure for the multivariable analysis.^d The four additional measures included isolation from friends, isolation from family, withholding money, and threats using immigration status in the past 12 months (0 = never or no, 1 = yes). A cumulative measure of lifetime experience of any family violence was also created.

Control variables

We controlled for sociodemographic characteristics including age, nativity, educational attainment, receiving public assistance (e.g., The Women, Infant, and Children Program, The Family Independence Program, cash welfare, and food stamps), marital status, and religiosity. Religiosity was measured using six items derived from Add Health, including level of importance of religion, belief that sacred scriptures of one’s religion is without mistake, frequency of attendance to religious services, frequency of prayer, belief in God, and importance of spirituality. These items were measured on Likert scales, where the highest values represented higher levels of religiosity and were recoded as a cumulative scale. Missing values were recoded into the modal category.

Analysis

First, we described the sociodemographic characteristic of the sample and prevalence of each type of family violence (Table 1). Next, we conducted principal components analysis with varimax rotation to assess the factor structure of the scale among women aged 18–65 years who had ever had sex.^e Then, we estimated alpha scores, mean, and range for each factor (Table 2). These methods were consistent with psychometric analyses conducted to assess the reliability of the original reproductive autonomy scale.¹¹ Using mean comparison tests, we then examined bivariate differences in mean scores for each reproductive autonomy subscale by type of family violence (Table 3). Multivariable linear regressions of each reproductive autonomy subscale were conducted by sociodemographic characteristics (Table 4) and then by each form of family violence (Table 5). All analyses were conducted using Stata/SE 18.0.

Table 1.

Sample Characteristics (N = 99)

	%/m	N	(SD)	Min	Max
Demographic characteristics
Age
18–24	21.2	21
25–31	26.2	26
32–38	11.1	11
39–44	18.2	18
45–52	23.2	23
53–65	4.0	4
Nativity
U.S.-born	58.6	58
Immigrant country/region of origina,b	41.4	41
Iraq	11.1	11
Lebanon	39.4	39
Syria	10.1	10
Yemen	10.1	10
Middle East otherb	6.1	6
North Africab	7.1	7
United States	11.3	11
Not reported	6.1	6
Highest level of education attained less than high school	23.2	23
Completed high school/GEDc	36.1	35
Bachelor’s degree or more	41.4	41
Receiving public assistance	44.4	44
Married	43.4	43
Religious affiliation
Muslim	95.9	94
Druze or Alewi	2.0	2
None	2.0	2
Religiosity	0.02		(0.934)	−2.5	1.2
Ever had sex	74.7	74
Lifetime experience of family violence
Any family violence	55.6
Isolation from family	20.2	20
Isolation from friends	22.2	22
Threaten using immigration status	12.1	12
Withholding money	9.1	9
Disrespect	51.5	51
Threaten	37.4	37
Physically hurt	38.4	38
Forced sexd	18.9	14

^a Approximately 90% (N = 52) of U.S.-born respondents indicated a non-U.S. country/region of origin.

^b For countries of origin with cell sizes <5, respondents were grouped within common region of origin to maintain anonymity of the respondent (“Middle East other” included respondents from Iran, Israel, Palestine, and Saudi Arabia; “North Africa” included respondents from Djibouti, Egypt, Morocco, Tunisia).

^c Includes those who completed some college or advanced degree.

^d Includes those who reported that they had ever had sex (n = 74).

Table 2.

Validation of Reproductive Autonomy Subscales (N = 74)

Subscale	Item	Rotated factor loadings
Communication3  Alpha = 0.9450  Mean = 2.895  Range = 1–4	1. My partner would support me if I wanted to use a method to prevent pregnancy.	0.493
	2. It is easy to talk about sex with my partner.	0.528
	3. If I did not want to have sex, I could tell my partner.	0.586
	4. If I was worried about being pregnant or not being pregnant, I could talk to my partner about it.	0.776
	5. If I really did not want to become pregnant, I could get my partner to agree with me.	0.793
Freedom from coercion3  Alpha = 0.9439  Mean = 3.438  Range = 1–4	1. My partner, or someone else (my parents, in-laws, or extended family member[s]), has stopped me from using a method to prevent pregnancy when I wanted to use one.	0.880
	2. My partner, or someone else (my parents, in-laws, or extended family member[s]), has messed with or made it difficult to use a method to prevent pregnancy when I wanted to use one.	0.839
	3. My partner, or someone else (my parents, in-laws, or extended family member[s]), has made me use a method to prevent pregnancy when I did not want to use one.	0.619
	4. If I wanted to use a method to prevent pregnancy my partner, or someone else (my parents, in-laws, or extended family member[s]), would stop me.	0.585
	5. My partner, or someone else (my parents, in-laws, or extended family member[s]), has pressured me to become pregnant.	0.551
Decision-making4  Alpha = 0.9047  Mean = 2.1655  Range = 1–3	1.Who has the most say about whether you use a method to prevent pregnancy?	0.525
	2.Who has the most say about which method you would use to prevent pregnancy?	0.377
	3.Who has the most say about when you have a baby in your life?	0.783
	4.If you became pregnant but it was unplanned, who would have the most say about whether you would raise the child, seek adoptive parents, or have an abortion?	0.809

(1) N = 74 includes those who ever had sex; (2) rotated factor loadings represent how the item is weighted for each factor and the correlation between the item and the factor; (3) response choices were strongly disagree, disagree, agree, and strongly agree; (4) response choices were my partner or someone else (my parents, in-laws, or extended family member[s]), both me and my partner equally, or me; (5) questions were asked in English or Arabic depending on the preference of the respondent.

Table 3.

Mean Comparisons of Reproductive Autonomy Subscales by Type of Family Violence (N = 74)

	Reproductive autonomy subscales
	Communication			Freedom from coercion			Decision-making
	M	SD	p	M	SD	p	M	SD	p
Isolation from family
Yes (N = 17)	2.2	−0.621	***	2.9	−0.605	***	2.1	−0.82	0.8
No (N = 57)	3.1	−0.804		3.6	−0.576		2.2	−0.532
Isolation from friends
Yes (N = 19)	2.2	−0.678	***	3	−0.661	***	2.1	−0.816	0.41
No (N = 55)	3.1	−0.783		3.6	−0.542		2.2	−0.517
Disrespect
Yes (N = 45)	2.5	−0.835	***	3.2	−0.702	***	2.1	−0.734	0.39
No (N = 29)	3.4	−0.572		3.8	−0.361		2.2	−0.31
Threatened using immigration status
Yes (N = 9)	2	−0.717	***	3	−0.717	*	2.1	−0.961	0.78
No (N = 65)	3	−0.804		3.5	−0.618		2.2	−0.548
Withholding money
Yes (N = 7)	2.1	−0.64	**	2.8	−0.73	**	2.1	−0.84	0.79
No (N = 67)	3	−0.837		3.5	−0.607		2.2	−0.583
Threatened
Yes (N = 33)	2.4	−0.864	***	3	−0.682	***	2.1	−0.806	0.25
No (N = 41)	3.3	−0.579		3.8	−0.412		2.2	−0.366
Hurt
Yes (N = 33)	2.3	−0.833	***	3.1	−0.702	***	2.1	−0.814	0.34
No (N = 41)	3.3	−0.591		3.7	−0.426		2.2	−0.357
Forced sex
Yes (N = 14)	2.3	−0.883	**	3	−0.672	**	2	−0.808	0.17
No (N = 60)	3	−0.798		3.5	−0.601		2.2	−0.544
Any family violence
Yes (N = 47)	2.6	−0.827	***	3.2	−0.698	***	2.1	−0.72	0.42
No (N = 27)	3.5	−0.579		3.8	−0.371		2.2	−0.314

N = 74 includes those who ever had sex.

*p < 0.05.

**p < 0.01.

***p < 0.001.

M, mean; SD, standard deviation.

Table 4.

Linear Regression of Reproductive Autonomy Subscales by Sociodemographic Characteristics (N = 74)

	Reproductive autonomy subscales
	Model 1	Model 2	Model 3
	Communication	Freedom from coercion	Decision-making
	b (95% CI)	b (95% CI)	b (95% CI)
	N = 74	N = 74	N = 74
Age (ref. 18–24 years)
25–31 years	−0.276	0.176	0.0291
	(−0.853 to 0.302)	(−0.345 to 0.697)	(−0.508 to 0.567)
32–38 years	−0.501	0.216	0.107
	(−1.288 to 0.285)	(−0.493 to 0.925)	(−0.625 to 0.839)
39–44 years	−0.662**	0.0559	0.223
	(−1.263 to −0.0600)	(−0.487 to 0.598)	(−0.337 to 0.783)
>45 years	−0.290	0.0785	0.253
	(−0.835 to 0.255)	(−0.413 to 0.570)	(−0.254 to 0.760)
U.S.-born	0.00483	0.0588	−0.147
	(−0.368 to 0.378)	(−0.278 to 0.395)	(−0.494 to 0.201)
Educational attainment (ref. less than high school)
HS diploma/ GED or some higher ed/AA	0.252	0.521**	0.0874
	(−0.231 to 0.736)	(0.0854 to 0.957)	(−0.362 to 0.537)
Bachelor’s degree or higher	0.601**	0.773***	0.103
	(0.0748 to 1.128)	(0.298 to 1.248)	(−0.388 to 0.593)
Receiving public assistance	−0.534***	−0.0890	0.0135
	(−0.884 to −0.184)	(−0.405 to 0.227)	(−0.313 to 0.339)
Married	0.666****	0.166	−0.0512
	(0.292 to 1.039)	(−0.171 to 0.503)	(−0.399 to 0.297)
Religiosity	−0.0726	−0.00423	−0.143*
	(−0.247 to 0.102)	(−0.162 to 0.153)	(−0.305 to 0.0193)
Constant	2.827****	2.763****	2.060****
	(2.103–3.550)	(2.111–3.416)	(1.386–2.733)

Includes those with a GED, some college education, or advanced degree like an associate’s degree or other vocational school.

^* p < 0.10.

^** p < 0.05.

^*** p < 0.01.

^**** p < 0.001.

CI, confidence interval.

Table 5.

Linear Regressions of the Reproductive Autonomy Subscales by Type of Family Violence (N = 74)

	Reproductive autonomy subscale: Communication
	Model 1	Model 2	Model 3	Model 4	Model 5	Model 6	Model 7	Model 8	Model 9
	Isolated from family	Isolated from friends	Withheld money	Threatened using immigration status	Disrespect	Threatened	Hurt	Forced sex	Any FV
	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)
	N = 74	N = 74	N = 74	N = 74	N = 74	N = 74	N = 74	N = 74	N = 74
Type of family violence	−0.617***	−0.597***	−0.606**	−0.594**	−0.435**	−0.523***	−0.561***	−0.39*	−0.415**
	(−1.013 to −0.222)	(−0.980 to −0.214)	(−1.166 to −0.0461)	(−1.081 to −0.108)	(−0.795 to −0.0741)	(−0.869 to −0.176)	(−0.901 to −0.221)	(−0.813 to 0.0337)	(−0.778 to −0.0530)
Constant	3.022****	3.078****	2.912****	2.943****	3.098****	3.140****	3.127****	2.892****	3.092****
	(2.332–3.711)	(2.381–3.775)	(2.204–3.619)	(2.240–3.646)	(2.365–3.831)	(2.428–3.852)	(2.430–3.824)	(2.178–3.606)	(2.354–3.829)

	Reproductive autonomy subscale: Freedom from coercion
	Model 10	Model 11	Model 12	Model 13	Model 14	Model 15	Model 16	Model 17	Model 18
	Isolated from family	Isolated from friends	Withheld money	Threatened using immigration status	Disrespect	Threatened	Hurt	Forced sex	Any FV
	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)
	N = 74	N = 74	N = 74	N = 74	N = 74	N = 74	N = 74	N = 74	N = 74
Type of family violence	−0.522***	−0.535***	−0.524**	−0.272	−0.376**	−0.538****	−0.489***	−0.472**	−0.346**
	(−0.882 to −0.161)	(−0.880 to −0.189)	(−1.030 to −0.0174)	(−0.726 to 0.182)	(−0.703 to −0.0501)	(−0.843 to −0.233)	(−0.797 to −0.181)	(−0.845 to −0.0982)	(−0.675 to −0.0171)
Constant	2.928****	2.988****	2.837****	2.817****	2.999****	3.086****	3.025****	2.842****	2.984****
	(2.300–3.556)	(2.359–3.618)	(2.197–3.477)	(2.160–3.473)	(2.335–3.662)	(2.458–3.714)	(2.393–3.657)	(2.213–3.472)	(2.315–3.654)

	Reproductive autonomy subscale: Decision-making
	Model 19	Model 20	Model 21	Model 22	Model 23	Model 24	Model 25	Model 26	Model 27
	Isolated from family	Isolated from friends	Withheld money	Threatened using immigration status	Disrespect	Threatened	Hurt	Forced sex	Any FV
	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)
	N = 74	N = 74	N = 74	N = 74	N = 74	N = 74	N = 74	N = 74	N = 74
Type of family violence	0.00533	−0.140	−0.0504	0.00685	−0.160	−0.163	−0.154	−0.359*	−0.178
	(−0.391 to 0.402)	(−0.521 to 0.242)	(−0.591 to 0.490)	(−0.467 to 0.481)	(−0.509 to 0.188)	(−0.506 to 0.180)	(−0.495 to 0.187)	(−0.754 to 0.0348)	(−0.527 to 0.170)
Constant	2.058****	2.119****	2.067****	2.059****	2.160****	2.158****	2.142****	2.120****	2.174****
	(1.368–2.749)	(1.424–2.814)	(1.384–2.750)	(1.373–2.744)	(1.451–2.869)	(1.453–2.863)	(1.444–2.841)	(1.455–2.785)	(1.464–2.883)

N = 74 includes those who ever had sex; all models control for age, nativity, educational attainment, receiving public assistance, marital status, and religiosity.

^* p < 0.10.

^** p < 0.05.

^*** p < 0.01.

^**** p < 0.001.

CI, confidence interval; FV, family violence.

Results

Sample characteristics

The sample included 99 Arab American women of which 21% were between the ages of 18 and 24 and nearly 60% were U.S.-born (see Table 1). Common countries of origin included Lebanon (39%), Iraq (11%), Syria (10%), Yemen (10%), Palestine (3%), and Tunisia (3%). Approximately 41% had a Bachelor’s degree or more, 44% were receiving public assistance, 43% were married, and three-quarters had ever had sex (N = 74). Over half (56%) reported any lifetime experience of family violence with disrespect as the most common (51.5%) followed by being physically hurt (38%) and threatened (37%). Approximately 20% had ever been isolated from their family and 22% from their friends, and among those who had ever had sex, 17% had experienced forced sex. Being threatened using immigration status (12%) and withholding earnings or savings (9%) were the least common forms of family violence in this sample.

Reliability of the reproductive autonomy subscales

Factor analysis indicated three factors for the reproductive autonomy scale that aligned with the communication, freedom from coercion, and decision-making subscales from the original measure (see Table 2). Items on the communication subscale had rotated factor loadings that ranged from 0.49 to 0.79 across five items, indicating moderate to strong association with this factor. The items on the freedom from coercion subscale indicated rotated factor loadings that ranged from 0.55 to 0.88, also indicating moderate to strong association with this factor. The decision-making subscale had rotated factor loadings that ranged from 0.37 to 0.81, indicating acceptable to strong association with the factor. Each of the subscales had high internal reliability (communication: alpha = 0.945; freedom from coercion: alpha = 0.944; decision-making: alpha =0.905). The mean level of communication with a partner was 2.9 (Min: 1, Max: 4), freedom from coercion was 3.4 (Min: 1, Max: 4), and decision-making was 2.2 (Min: 1, Max: 3).

Bivariate associations between family violence and reproductive autonomy

Those who were isolated from friends or family, disrespected, threatened due to immigration status, had money withheld, were threatened, hurt, or forced to have sex by a partner or other family member had significantly lower mean scores on the communication and freedom from coercion subscale (see Table 3).

Sociodemographic correlates of reproductive autonomy

Adjusted models indicated that having a Bachelor’s degree and being married were significantly associated with higher levels of communication. Being older (39–45 years compared with 18–24 years) and receiving public assistance were significantly associated with lower levels of communication (Table 4; Model 1). Freedom from coercion was significantly associated with educational attainment; those who had a high school diploma or Bachelor’s degree or more had higher scores on the communication subscale compared with those who had less than a high school degree (Table 4; Model 2).

Multivariable associations between family violence and reproductive autonomy

Isolation from family and friends, having money withheld, being threatened using one’s immigration status, disrespected, threatened, physically hurt, or experiencing any form of family violence were significantly associated with lower levels of communication (Table 5; Models 1–9). Isolation from family and friends, having money withheld or being disrespected, threatened, physically hurt, forced to have sex, and any family violence were also associated with lower levels of freedom from coercion (Table 5; Models 10–18). Those who were forced to have sex tended to have lower decision-making scores (b = −0.359), but the association was marginally significant (p < 0.10) (Table 5; Model 26).

Discussion

The current study assessed the prevalence of family violence and levels of reproductive autonomy among Arab American women residing in Dearborn, Michigan, and if family violence was associated with reproductive autonomy within this community. We found that nearly 60% of the sample had some prior experience family violence with disrespect from a partner being the most common followed by being physically hurt and threatened. Additionally, reliability of the multidimensional reproductive autonomy scale was high within this sample. We also found that sociodemographic characteristics such as educational attainment and public assistance increased reproductive autonomy, and several forms of family violence were associated with lower levels of communication with a partner and freedom from coercion.

Our findings on prevalence of family violence were lower than physical and emotional (e.g., disrespect and threats) violence reported in other Arab American samples.¹² It is possible that our findings may underreport experiences with family violence due to stigma and concerns regarding family honor and cohesion.²⁴ Additionally, although past qualitative work on intimate partner violence in the Arab community has found that open discussion on sexual violence is rare,⁶ at least 17% of women in the sample who indicated that they had ever had sex reported forced sex.

The reproductive autonomy scale developed by Upadhyay and colleagues¹¹ was also reliable for use within this Arab American sample. Not only was there moderate to strong association between items within each factor, but each scale also indicated high levels of reliability. Additionally, questions from the reproductive autonomy scale were piloted in English and Arabic, suggesting that in addition to being culturally appropriate, it has been appropriately translated to meet the linguistic needs of this specific Arab American community.

Several sociodemographic factors were also associated with each of the subscales. For example, higher levels of educational attainment were associated with greater communication and freedom from coercion from a partner, and those who had received public assistance had lower levels of communication with a partner. These findings are similar to other studies that show that higher levels of education can empower women to move from lower positions of power to exercising control in their life including over their reproductive decisions.^25–28 Women with higher education are also more likely to be informed about their health and well-being and equipped to address their reproductive health needs.²⁹ Additional factors, such as religiosity, may be important to also consider within this sample, especially since the vast majority of respondents were Muslim. In fact, clinicians and other health care providers should be aware and able to distinguish Islamic religious perspectives from cultural perspectives regarding pregnancy and childbearing when supporting Arab American women in making decisions regarding their reproductive health and childbearing.

Finally, our study indicated that several forms of family violence were associated with lower levels of communication with a partner and freedom from coercion. These findings align with other studies that have been conducted among Latinx and Black women that show how prior experiences with an intimate partner make it difficult for women to negotiate contraception use and make autonomous decisions regarding their contraceptive preference.^21,30–33 The high importance placed on extended family in Arab cultural norms may make Arab American women more susceptible to pressure regarding their reproductive intentions. Within an Arab family unit, women have an important cultural and social role in helping the family grow and assuring the continuation of the family lineage through their willingness and ability to have children.³⁴ Such norms may exacerbate feelings of pressure to make reproductive decisions that appease familial expectations instead of meeting one’s own needs and goals related to reproduction. Future studies should explore if experiences with family violence have other consequences for reproductive health among Arab American women. For example, it would be important to examine if women who have experienced family violence and lower reproductive autonomy are also at risk of experiencing unintended pregnancy, abortion, miscarriage and stillbirth, or other adverse birth outcomes.

Strengths and limitations

The data used in this study were cross-sectional, and causality cannot be inferred from the findings. The study also consisted of a convenience sample that was recruited through a community health organization. Therefore, there may be selection bias and limited generalizability to Arab American women who are not seeking health services or are living in areas that do not have a densely concentrated Arab American population.³⁵ As a pilot study, however, this was appropriate for understanding family violence and reproductive autonomy within this community. Another limitation of this study is that questions regarding sex and gender were not explicitly asked in the survey due to the potential sensitivity of such questions for the community. Still, all participants were asked if they self-identified with the eligibility criteria of being 18–65 years old and an Arab American women through a comprehensive informed consent process. Finally, due to stigma around conversations on violence between intimate partners and women’s bodies in Arab culture,^34–37 our reports of family violence and reproductive autonomy may be subject to underreport. However, in offering the survey independently or with a trusted provider according to the respondents’ preferences and allowing the respondents to choose if they wanted to take the survey in English or Arabic, we attempted to minimize barriers to participation. This study offers important insights on family violence and adverse consequences of family violence for reproductive health among Arab American women.

Clinical implications

Clinicians should consider the role of partners and other family members such as in laws, natal family, and other extended family, when addressing the reproductive health needs of Arab American women. The reproductive autonomy measure in this study would also be useful for clinicians who are assisting Arab American women to address and achieve their reproductive goals. Furthermore, given the associations between several types of family violence and communication with and freedom from coercion from a partner, this study suggests that screening and counseling for family violence in reproductive health clinics would be important to integrate in locations where Arab American women seek reproductive health care.

Conclusion

There are several important contributions of this study. First, this study reports on several types of family violence of varying severity within an Arab American population. This study is also the first to assess the validity of the multidimensional reproductive autonomy scale that focuses on interpersonal dynamics¹¹ and report associations between multiple forms of family violence and dimensions of reproductive autonomy among Arab American women. Future work should continue to explore the reproductive health consequences of family violence among Arab American women and how Arab American women can be assisted in exercising their full range of reproductive rights, including having autonomy in their reproductive decisions.

Authors' Contributions

A.G.K. developed the research questions, study proposal, data collection instruments, data analysis, and drafted the manuscript. J.G. assisted in data cleaning, management, and analysis. M.M. served as a community co-investigator and contributed to building the community-university partnership, research questions, study proposal, data collection, and manuscript review. M.T. served as a community partner and contributed to building the community-university partnership, research questions, study proposal, data collection, and manuscript review. Y.K. provided mentored guidance on development of research questions, study proposal, development of data collection instrument and data management, support in data analysis, and review of the manuscript.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH).

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This research was supported by the ACCESS Community Health and Research Center, the Michigan Institute for Clinical and Health Research, the NIH National Center for Advancing Translational Sciences (2UL1TR000433), and the National Institute of Aging training grant to the UM Population Studies Center (T32AG000221).