Reproductive coercion and intimate partner violence among rural women in Côte d’Ivoire: a cross-sectional study

Abstract

A growing body of U.S.-based research demonstrates that reproductive coercion is an important consideration regarding the negative health impacts of intimate partner violence (IPV). However, less work on IPV and reproductive coercion has been done in West African settings. Cross-sectional data of 981 women who participated in the baseline survey of a randomized-controlled trial in rural, Cote d’Ivoire in October 2010 were analyzed for specific reports of reproductive coercion. Half (49.8%) of all women reported lifetime physical or sexual IPV, and nearly 1 in 5 (18.6%) reported experiencing reproductive coercion. In the final adjusted analyses, lifetime IPV was associated with a 3.7 increase in odds of reporting reproductive coercion (95% CI: 2.4 – 5.8) compared to women who did not report such victimization. Study findings underscore the importance of reducing IPV in order to improve reproductive health among women in rural Cote d’Ivoire.

Introduction

Male perpetrated intimate partner violence (IPV) against women is an egregious human rights concern that has been estimated to occur among 15 to 76%^1,2 of women across multiple global settings at some point in their lifetime. An extensive body of research has documented a range of negative reproductive health consequences arising from women’s experiences with IPV which includes unintended pregnancy, fetal loss, maternal morbidity and mortality, and increased vulnerability to sexually transmitted infections, including HIV^3–8. As such, there are increasing efforts to better understand the specific mechanisms by which such violence can impact a woman’s reproductive health. In both developed and developing country settings, women’s lack of control over reproductive health decisions where violence is present, has been underscored as an important element underlying such relationships^9–11.

In addition to reproductive decision-making, a growing body of research has also demonstrated how reproductive coercion, which can involve explicit pressure from the partner to become pregnant, or actual manipulation of birth control, can increase a women’s vulnerability to poor reproductive health in situations where IPV is present^12,13. To date, however, the majority of this research has taken place with populations within the United States, with an emphasis on attendees of health clinics that focus on the provision of reproductive health/family planning services¹⁴. The extent to which such findings apply in other contexts, particularly in developing countries, including those impacted by conflict as well as non-clinical settings, is currently unclear.

The investigation of the potential links between IPV and reproductive coercion is of particular importance in developing country contexts. In Cote d’Ivoire, a West African nation that has been grappling with armed conflict and political instability for over a decade, both IPV and poor reproductive health of women are concerns. Community-based work has documented that 47% of rural Ivorian women report having ever experienced IPV from a male partner¹⁵. Equally grim are this country’s key reproductive health indicators as almost 30% of women are reported to have unmet family planning needs¹⁶ and a woman has a 1 in 53 risk of maternal death¹⁷. It is important to situate these sexual and reproductive health statistics in current global development agendas where increasing a woman’s utilization of family planning is being re-highlighted as a key development priority within the Millennium Development Goals¹⁸. Prominent within these discussions is the prioritization of a woman’s decision-making processes and autonomy regarding family planning or other reproductive health care utilization¹⁸. Therefore, it is critical to examine partner-perpetrated reproductive coercion within Cote d’Ivoire as well as other developing nations, including those impacted by political conflict. Such investigations should include the relationship reproductive coercion may have with other forms of victimization, given the potential dual burden women face in these contexts and compounding of negative effects on reproductive health.

The investigation of IPV and male partner perpetrated reproductive coercion is further indicated by a recent study with rural Ivorian women which documented that women who reported abuse from in-laws were more likely to experience reproductive coercion from their male partners’ family members¹⁹. IPV from partners and abuse from in-laws have been documented to co-occur in other global contexts^20–22. Similar to violence perpetration, a comparable relationship may be seen regarding male-perpetrated reproductive coercion. Thus, the objectives of the current study are to: 1) document the lifetime prevalence of physical and/or sexual IPV; 2) document the forms of male partner perpetrated reproductive coercion, and 3) investigate the relationship between lifetime IPV experiences and partner perpetrated reproductive control among partnered women residing in rural Cote d’Ivoire.

Methods

Subjects and settings

This secondary analysis used data from a baseline survey of a community-based randomized controlled trial (trial registration number NCT01629472) led by Yale School of Public Health (YSPH), and Innovations for Poverty Action (IPA) in partnership with the International Rescue Committee (IRC), The objective of the parent trial was to assess the effectiveness of village savings and loans programs with gender dialogue groups in conflict-affected communities on the reduction of IPV. Rural villages were chosen for inclusion in the trial in northwestern Cote d’Ivoire; women were eligible for the intervention if they were over the age of 18 years and had no previous experience with microfinance. Further intervention details are found elsewhere^19–23. For the present analysis, the study sample was restricted to women who reported having a partner at the time of the baseline survey.

Study procedures

Surveys were conducted with women with language matched female interviewers in a private location. Lifetime physical and/or sexual IPV was assessed via items from the WHO multi-country study on domestic violence and women’s health¹. Any affirmative response to an item was coded as experiencing IPV in a summary, binary variable. Lifetime reproductive coercion was assessed through nine items previously developed by Miller, et al¹² to assess pregnancy pressure and birth control sabotage. Specifically, women were asked if their partner has ever: (1) told you not to use birth control; (2) said he would leave you if you did not get pregnant; (3) told you he would have a baby with someone else if you didn’t get pregnant; (4) tried to force or pressure you to become pregnant; (5) taken off a condom while you were having sex; (6) put holes in the condom so you would get pregnant; (7) taken your birth control away from you; and (8) made you have sex without a condom. An additional item asked the woman if she had ever hidden birth control from her partner because she was afraid he would get upset with her for using it. Any ‘yes’ response was coded as experiencing reproductive coercion in the final binary, summary variable. The scale demonstrated high internal consistency reliability (Cronbach’s α=0.89).

Ethical approval

All study procedures received ethical approval from the Yale School of Public Health and Innovations for Poverty Action.

Statistical analysis

Descriptive statistics and bivariate associations were assessed between intimate partner violence, reproductive coercion, and demographic variables using Wald Type 3 effect p-values from bivariate generalized estimating equations (GEE) that accounted for clustering at the village level. Unadjusted and adjusted odds ratios were estimated through logistic GEE models. All analyses were conducted in SAS 9.2 and statistical significance was set at the p <0.05 level.

Results

Sample Characteristics

A total of 1,273 women who were approached completed the survey; the overall response rate was 96%. Of these, 981 women reported having a male partner at the time of the survey (77.1%). Overall, almost one in five women reported lifetime partner-perpetrated reproductive coercion (18.6%) and almost half (49.8%) of women reported experiencing physical or sexual violence from their partner in their lifetime (Table 1). The mean age of women was 37.4 years and the majority had not received formal schooling (Table 2). The most common religion was Christian and the majority of respondents were of Yacouba ethnicity. Over 80% of women were married and nearly three-quarters of women had four or more pregnancies.

Table 1.

Frequency of lifetime intimate partner violence and lifetime reproductive coercion (n=981).

	Reproductive Coercion % (n)	No Reproductive Coercion % (n)	Total % (n)
IPV % (n)	27.9 (136)	72.1 (352)	49.8 (488)
No IPV % (n)	9.3 (46)	90.7 (447)	50.3 (493)
Total % (n)	18.6 (182)	81.4 (799)	981

Table 2.

Associations of participant characteristics and lifetime intimate partner violence and lifetime reproductive coercion (n=981).

	% (n) or Mean (SD)	Lifetime IPV % (n) or Mean (SD)	P*	Reproductive Coercion % (n) or Mean (SD)	P*	Missing % (n)
Age	37.4 (11.3)	36.8 (10.6)	0.2	34.5 (10.2)	0.005	0.0 (0)
Education
None	71.4 (698)	46.7 (326)	0.0002	15.2 (106)	<0.0001	0.3 (3)
Primary	22.2 (217)	61.3 (133)		28.1 (61)
Secondary or Higher	6.4 (63)	44.4 (28)		23.8 (15)
Religion
Christian	43.1 (423)	48.7 (206)	0.5	21.8 (92)	0.1	0.0 (0)
Muslim	17.0 (166)	45.2 (75)		10.8 (18)
Traditional	16.8 (164)	51.2 (84)		18.3 (30)
Other or None	23.2 (228)	54.0 (123)		18.4 (42)
Ethnicity
Yacouba	62.3 (611)	50.1 (306)	0.0002	19.8 (121)	0.01	0.0 (0)
Baoule	11.5 (113)	54.9 (62)		18.6 (21)
Guere	7.1 (70)	57.1 (40)		21.4 (15)
Senoufo	5.9 (58)	34.5 (20)		8.6 (5)
Dioula	3.7 (36)	63.9 (23)		25.0 (9)
Other	9.5 (93)	39.8 (37)		11.8 (11)
Marital Status
Married	84.3 (823)	49.1 (404)	0.06	16.2 (133)	0.003	0.5 (5)
Living with partner	11.0 (108)	58.3 (63)		31.5 (34)
Not living with partner	4.6 (45)	44.4 (20)		28.9 (13)
Number of Pregnancies
0	3.0 (29)	37.9 (11)	0.1	24.1 (7)	0.3	0.0
1 – 3	24.0 (235)	46.8 (110)		23.8 (56)
≥ 4	73.1 (717)	51.2 (367)		16.6 (119)

^*Wald Type 3 p-values derived from bivariate GEE models, adjusting for correlation at the village level

Bivariate associations with reproductive coercion

Among those who reported reproductive coercion, 27.9% also reported lifetime IPV, compared to 9% who did not experience such victimization (p<0.0001). In the unadjusted GEE odds ratio estimates, women who reported lifetime IPV were 3.8 times more likely to report reproductive coercion than those who did not report such violence (95%CI: 2.4 – 6.0) (Table 3). In the unadjusted analyses, lowered odds of reproductive coercion were associated with older age (OR: 0.97; 95%CI: 0.95 – 0.99) and Christian religion (OR: 0.4; 95%CI: 0.2 – 0.9). Heightened odds of reproductive coercion were associated with primary (OR: 2.2; 95%CI: 1.7 – 2.8) or secondary school (OR: 1.7; 95%CI: 1.1 – 2.7), living with a partner, but not married (OR: 2.4; 95%CI: 1.3 – 4.4) and partnered, but not living together or married (OR: 2.1; 95%CI: 1.03 – 4.3). No other demographic factors were associated significantly with reproductive coercion.

Table 3.

Unadjusted and adjusted odds ratios estimates of reporting reproductive coercion among rural Côte d’Ivorian women.

	Unadjusted Reproductive Coercion Odds Ratio (95% CI)	P*	Adjusted Reproductive Coercion Odds Ratio (95% CI)	P*
Lifetime IPV (Physical or Sexual)
Yes	3.8 (2.4 – 6.0)	<0.0001	3.7 (2.4 – 5.8)	<0.0001
No	Ref		Ref
Age	0.97 (0.95 – 0.99)	0.005	0.98 (0.96 – 0.99)	0.03
Education
None	Ref		Ref
Primary	2.2 (1.7 – 2.8)	<0.0001	1.7 (1.3 – 2.4)	0.0004
Secondary or Higher	1.7 (1.1 – 2.7)	0.01	1.8 (1.0 – 3.0)	0.03
Religion
Christian	Ref		Ref
Muslim	0.4 (0.2 – 0.9)	0.02	0.3 (0.1 – 0.6)	0.001
Traditional	0.8 (0.5 – 1.2)	0.3	0.9 (0.7 – 1.4)	0.8
Other or None	0.8 (0.5 – 1.2)	0.3	0.7 (0.5 – 1.1)	0.1
Ethnicity
Yacouba	Ref		Ref
Baoule	0.9 (0.4 – 2.0)	0.8	0.7 (0.3 – 1.3)	0.2
Guere	1.1 (0.8 – 1.6)	0.6	0.8 (0.4 – 1.5)	0.5
Senoufo	0.4 (0.2 – 0.9)	0.02	1.2 (0.5 – 3.1)	0.7
Dioula	1.3 (0.6 – 2.8)	0.4	2.6 (1.1 – 6.0)	0.02
Other	0.5 (0.3 – 0.9)	0.05	0.6 (0.4 – 0.9)	0.04
Marital Status
Married	Ref		Ref
Living with partner	2.4 (1.3 – 4.4)	0.007	1.6 (0.8 – 2.9)	0.2
Not living with partner	2.1 (1.03– 4.3)	0.04	2.0 (0.9 – 4.2)	0.06
Number of Pregnancies
0	1.6 (0.8 – 3.2)	0.2	2.2 (1.3 – 3.7)	0.005
1 – 3	1.6 (0.9 – 2.7)	0.1	1.4 (0.7 – 2.6)	0.3
≥ 4	Ref		Ref

^*Estimates derived from logistic generalized estimating equations, accounting for clustering at the village level.

Adjusted associations with reproductive coercion

In the final adjusted analyses, lifetime IPV was associated with a 3.7 increase in odds of reporting reproductive coercion (95% CI: 2.4 – 5.8) compared to women who did not report such victimization, adjusting for covariates and correlation at the village level (Table 3). Older age and not attending formal school were associated with reduced odds of reporting reproductive coercion. Women who had never been pregnant were 2.2 times more likely to report reproductive coercion (95%; CI: 1.3 – 3.7) compared to women who had four or more pregnancies. Compared to Yacouba women, Dioula women were 2.6 times more likely to report reproductive coercion (95%CI: 1.1 – 6.0). Muslim women were less likely to report reproductive coercion compared to Christian women (aOR: 0.3; 95%CI: 0.1 – 0.6). In the final model, living with a partner, but not married (aOR: 2.2; 95%CI: 1.3- 3.7) and partnered, but not married or living together (aOR: 2.0; 95%CI: 0.9–4.2) were not associated with reproductive coercion.

Discussion

Half (49.8%) of rural Ivorian women in the community-based sample reported experiencing physical and/or sexual IPV from a male partner at some point in their lifetime, demonstrating that IPV is commonplace in this region, regardless of marital status. This high prevalence of IPV is comparable to the range suggested in the small amount of IPV estimates in Cote d’Ivoire^15,24, and is comparable within the range of the few IPV estimates that have been conducted among conflict-affected nations in West Africa^25–27.

The current study also documents a significant relationship between IPV and reported experiences of partner perpetrated reproductive coercion. Specifically, women with experiences of IPV were more than three times more likely to report reproductive coercion than their counterparts who did not report IPV. Findings from the present investigation are consistent with US-based work that is one of the few existing investigations that has explicitly examined the link between IPV and partner perpetrated reproductive coercion^12–14. These findings also parallel prior work documenting women’s experiences of IPV and decreased reproductive autonomy^28,29, and underscore the reproductive health threats faced by women in Cote d’Ivoire due to violence from their partners. Moreover, prior work in Cote d’Ivoire has demonstrated an association between abuse from in-laws (i.e. family members of male partners), and in-law perpetrated reproductive coercion¹⁹. The current investigation documents that reproductive coercion is also more likely to be exacted by male partners in the context of IPV in this West African nation. Together, these studies call for the importance of reducing IPV both to improve the well-being of women, but also to improve the reproductive health, and potential mental health³⁰ of Ivorian women.

Notable differences in IPV experiences based on ethnicity were observed. In this sample of Ivorian women, a higher prevalence of IPV was observed among women who identified as Yacouba, Guere, or Dioula. More research is needed to understand these findings, and may provide important information for the development of culturally tailored programs for these particular ethnicities. For instance, many of these groups are of ethnic minority status in Cote d’Ivoire, and thus have a long history of experiences of discrimination as well as ethnically-motivated violence. Both of these exposures have been associated with increased IPV in other contexts ^31–35 and thus the trauma, along with the loss of economic livelihood, as well as pervasive gender norms disfavoring women may all need to be addressed in these populations to reduce IPV.

Inconsistent with prior research³⁶ no significant differences were observed regarding number of pregnancies and IPV experiences. However, consistent with the aforementioned study in Côte d’Ivoire examining in-law abuse and in-law perpetrated reproduction coercion, women who reported zero pregnancies were over twice as likely to experience reproductive coercion than women with 4 or more pregnancies¹⁹. While more research is needed to understand this observation, culturally prescribed gender norms may be driving this as prior work across multiple global contexts have documented the social pressure faced by women from both partners and partners’ family to produce children both to preserve status within the community and viewing women as responsible for miscarriage and/or inability to conceive^37–39. It has been recommended to encourage women to utilize discreet forms of contraception (i.e. injectables) as an effective means to reduce unwanted pregnancy and avoid conflict with husbands/partners regarding the use of contraception¹⁰. Such longer term methods have also been recommended for disaster-affected populations to ensure protection from unwanted pregnancy in crisis situations where it may be difficult to adhere to regimens⁴⁰. However, current observations suggest the need for research on how discreet methods may protect women from coercion and maltreatment in the long term, particularly in societies where childless women are less valued³⁹, thus underscoring the importance of simultaneously addressing cultural norms regarding gender and women’s status in this community.

The findings of this study are best considered with the acknowledgment of important limitations. Firstly, temporality cannot be ascertained due to the cross-sectional design. Additionally, the findings of this study are best applied to women whose demographics are represented herein; the sample was not drawn from a probability based-sample and women in the current study had to meet strict inclusion criteria. Lastly, as with most research on IPV, both IPV and reproductive coercion may be underreported, due to stigma. In addition, this study was not able to examine the differential impacts of IPV and reproductive coercion on reproductive health outcomes, such as unintended pregnancies, which is an opportunity for future research.

Despite these limitations, the present study does have important implications for programming. Current data highlight the importance of integrating IPV reduction efforts into existing reproductive health services in Côte d’Ivoire and potentially other populations in West Africa that are affected by conflict. This may include health care provider-delivered interventions that are designed to screen and assist women with IPV experiences. In Cote d’Ivoire and other settings affected by conflict, services for violence against women, including clinic or health care provider-based interventions, increasing efforts have been recommended to address war-related sexual violence against women (i.e., sexual violence that was perpetrated by armed actors) in clinic-based settings^41,42. Data from the present study indicate the importance of also addressing comprehensive IPV screening and assistance protocols as part of such programming, including the distinct features of IPV, such as its chronic nature as well as the perpetrator being someone whom the woman may be dependent upon economically that warrant safety planning and harm reduction as part of health care provider-delivered counseling⁴³. The integration of IPV reduction efforts into community-based reproductive health programming is also indicated, which may include providing education to providers as well as community members regarding the links between IPV and reproductive health.

Within humanitarian programming, provision of and access to family planning has been highlighted as a key component of sexual and reproductive health programs^44,45. These recommendations resonate with the recent multi-organization movement to commit to increasing family planning utilization¹⁸. Indeed, it is critically important to provide reproductive health and family planning services to conflict-affected settings, such as in rural Cote d’Ivoire⁴⁶ and to address traditional barriers including lack of information as well as improvement of health systems^47,48. However, such programs must also work to improve the reproductive autonomy of women, as well as the larger social and gender norms that may prevent women from utilizing such contraception and simultaneously perpetuate IPV, which may be particularly relevant for countries in the post-conflict period or among populations affected by protracted crises. Additionally, future work is needed to assess how community-based socioeconomic empowerment interventions aimed to reduce IPV might impact the forms of reproductive coercion assessed in this present investigation. The reduction of IPV and associated reproductive coercion of women has enormous potential to improve the overall reproductive health of women in this West African country.