Abuse from in-laws and associations with attempts to control reproductive decisions among rural women in Côte d'Ivoire: a cross-sectional study

Reproductive Coercion: Prevalence and Risk Factors Related to Relationship Health Knowledge and Skills

Reproductive coercion is any behavior that limits a person's reproductive decision-making and can lead to negative health and safety outcomes. Previous research has explored reproductive coercion prevalence rates in clinical samples, as well as demographic risk factors for experiencing reproductive coercion. The purpose of this study is to assess the prevalence rates of two specific forms of reproductive coercion, pregnancy coercion and condom manipulation, in an ethnically and racially diverse sample of young females. We also explore the association between relationship health knowledge and skills with reproductive coercion. We used a sample of 143 females with previous sexual activity. Participants were diverse in terms of race, ethnicity, sexual orientation, and family immigration status. Descriptive statistics and logistic regression analyses were used to determine prevalence rates of pregnancy coercion and condom manipulation and the likelihood of experiencing reproductive coercion based on participants' knowledge and skills related to relationship health. Results revealed that 16.1% of the sample had experienced reproductive coercion, with all participants in this group reporting lifetime experiences of pregnancy coercion. Lifetime experiences of condom manipulation were reported by 6.3% of the sample. The most common form of reproductive coercion experienced by participants was being told by a partner not to use any birth control. Furthermore, results indicate that higher relationship health knowledge may be a protective factor for pregnancy coercion and condom manipulation. Likewise, higher decision-making skills in relationships and higher confidence in relationships may also protect against condom manipulation. Results from this study suggest implications for sexual and relationship health programming that expands education around consent, choice, decision-making, and communication around the use of contraception.

A Latent Class Analysis of Reproductive Coercion Experiences Based on Victim-Survivors' Acknowledgment and Disclosure Patterns

Reproductive coercion (RC) is a form of violence involving behavior that interferes with an individual's contraceptive and reproductive decisions. Like other forms of violence perpetrated by intimate partners, victims of RC do not necessarily identify it as such. Similarly, victim-survivors do not readily disclose their experiences or seek support and treatment. This study identifies patterns of acknowledgment and formal and informal disclosure of RC experiences in a community sample of 317 participants. Latent classes are then compared with respect to characteristics of victims/survivors, RC consequences, and associated contexts. Participants completed measures to assess experiences of RC and violence perpetuated by intimate partners as well as social support, posttraumatic stress symptoms, and consequences for psychological and sexual health. Latent class analysis was performed to identify acknowledgment and disclosure patterns. An optimal three-class solution was selected: High unacknowledgment with ambivalence, High disclosure (41%); High acknowledgment, High disclosure (30%); and Hesitant acknowledgment, No disclosure (29%). Classes were identified according to the presence of social support, living with a disability, victimization experiences, and mental and sexual health consequences. Future studies should explore the relationship between RC acknowledgment and disclosure, which can influence victims' search trajectories for support and services.

A qualitative exploration of reproductive coercion experiences and perceptions in four geo-culturally diverse sub-Saharan African settings

Reproductive coercion (RC) is any intentional behavior that interferes with another's reproductive decision-making or pregnancy outcome. This study aims to qualitatively examine RC experiences and perceptions among women and men in Ethiopia, Nigeria (Kano and Anambra States), and Uganda. This is a secondary analysis utilizing qualitative data from the Women's and Girls' Empowerment in Sexual and Reproductive Health study. Across sites, focus group discussions (38 groups; n=320 participants) and in-depth interviews (n=120) were conducted, recorded, and transcribed. Transcripts were loaded into Atlas.ti, and quotes describing experiences of reproductive control or abuse were coded as "reproductive coercion." RC quotes were input into a matrix for thematic analysis. Emergent RC themes included indirect reproductive pressures, direct family planning interference, concurrent experiences of violence, and responses to RC. Indirect reproductive pressures included tactics to both promote and prevent pregnancy, while direct interference centered on pregnancy promotion. Women who were not compliant with their partners' reproductive demands were often subjected to violence from multiple actors (i.e., parents, in-laws, community members) in addition to their partners. Despite concurrent forms of violence, women across sites resisted RC by using contraceptives covertly, choosing to abort, or leaving their abusive partnerships. Women and men across sites indicated that men were highly influential in fertility. RC behaviors were a mechanism of control over desired reproductive outcomes, which were often rooted in perceptions of childbearing as social status. Findings indicate a need for more nuanced community interventions targeting social norms, as well as improved RC screening and response within health services.

Reproductive Autonomy in Appalachia: An Investigation into Perceived Contraceptive Pressure

The reproductive autonomy of persons who can give birth can be impeded through forms of interpersonal violence and coercion. Moreover, macro-level factors (e.g., poverty, discrimination, community violence, legislative policies) may impede the reproductive autonomy of entire communities. This study investigates a form of violence we term perceived contraceptive pressure in Appalachia, an understudied region of the Eastern U.S., regarding reproductive health and decision-making. Through targeted Meta advertising, participants (N = 632) residing in Appalachian zip codes completed an online survey on reproductive health. The focus of this study was to investigate the prevalence of perceived contraceptive pressure, who was at increased risk of experiencing pressure, and the source(s) of perceived pressure. Binomial regressions were conducted on three different dependent variables: perceived pressure to be sterilized, perceived pressure to use birth control, and perceived pressure not to use birth control. Approximately half of all respondents (49.5%) reported experiencing at least one type of pressure targeting contraceptive decision-making. The most prevalent source of perceived pressure to use birth control was from the healthcare provider (67.4%), and the most prevalent source of perceived pressure not to use birth control was the respondent's partner (51.1%). Recommendations for providers serving clients in the Appalachian region include pursuing education regarding contraceptive pressure at the individual level and macro-level. In addition, Appalachian residents may benefit from educational programming on reproductive autonomy, healthy relationships, and how to navigate pressure in relationships.

Intimate partner violence against women of reproductive age and associated factors during COVID-19 pandemic in Northern Ethiopia, 2021: A community-based cross-sectional study

Background

Intimate partner violence (IPV) is a major public health concern that affects more than one-third of all women globally. Assessing the prevalence of intimate partner violence and associated factors during the COVID-19 pandemic in various localities is crucial for intervention actions. So far, a few studies have been done in Ethiopia during the current COVID-19 pandemic.

Objective

This study aimed to assess the prevalence of intimate partner violence in women of reproductive age and associated factors during the COVID-19 pandemic in Debre Berhan town, Ethiopia, 2021.

Methodology

A community-based cross-sectional study was done. A total of 809 ever-partnered women of reproductive age were selected randomly via a multistage sampling method. Crude and adjusted odds ratios (AOR) with the resulting 95% confidence interval (CI) were used to verify the strength of associations. Significant associations were declared at p-values <0.05.

Result

Among the 796 women who successfully participated in the study, 337 (42.3%) experienced at least one type of intimate partner violence. Prevalence of psychological, physical, and sexual violence was 35.3% (281), 15.3% (122), and 15.2% (121), respectively. Multivariate analysis revealed that women with no formal education [AOR (95% CI): 3.66 (1.91-6.98)], having no own income [AOR (95% CI): 1.78 (1.24-2.56)], and attitude of IPV were acceptable [AOR (95% CI): 4.02 (1.33-12.14)]; a male partner with no formal education [AOR (95% CI): 3.06 (1.53-6.14)], with "level of religious beliefs" [weak-AOR (95% CI): 4.17 (1.45-12.03); and medium-AOR (95% CI): 1.64 (1.13-2.39)], who is alcoholic [AOR (95% CI): 5.91 (4.03-8.67)], and with smoking habits [AOR (95% CI): 2.04 (1.10-3.77)] and >5 [AOR (95% CI): 1.83 (1.01-3.39)] was significantly associated with the presence of intimate partner violence.

Conclusion and recommendation

This study revealed a high prevalence of IPV in the study participants. The high intimate partner violence prevalence was due to multiple factors, thus demanding empowering women and tailored health education for male partners.

Prevalence and correlates of reproductive coercion across ten sites: commonalities and divergence

BACKGROUND

Reproductive coercion (RC) is a type of abuse where a partner asserts control over a woman's reproductive health trajectories. Recent research emphasizes that RC experiences may differ within and across low- and middle-income countries (LMICs), as compared to higher income contexts, given social pressures surrounding childbearing. To date, nationally representative surveys have lacked comprehensive measures for RC, leading to gaps in understanding its prevalence and risk factors. Across eight LMICs (10 sites), we aimed to (1) validate the RC Scale; (2) calculate prevalence of RC and specific behaviors; and (3) assess correlates of RC.

METHODS

This analysis leverages cross-sectional Performance Monitoring for Action (PMA) data collected from November 2020 to May 2022. Analyses were limited to women in need of contraception (Burkina Faso n = 2767; Côte d'Ivoire n = 1561; Kongo Central, Democratic Republic of Congo (DRC) n = 830; Kinshasa, DRC n = 846; Kenya n = 4588; Kano, Nigeria n = 535; Lagos, Nigeria n = 612; Niger n = 1525; Rajasthan, India n = 3017; Uganda n = 2020). Past-year RC was assessed via five items adapted from the original RC Scale and previously tested in LMICs. Confirmatory factor analysis examined fit statistics by site. Per-item and overall prevalence were calculated. Site-specific bivariate and multivariable logistic regression examined RC correlates across the socioecological framework.

RESULTS

Confirmatory factor analysis confirmed goodness of fit across all sites, with moderate internal consistency (alpha range: 0.66 Cote d'Ivoire-0.89 Kinshasa, DRC/Lagos, Nigeria). Past-year reported prevalence of RC was highest in Kongo Central, DRC (20.3%) and lowest in Niger (3.1%). Prevalence of individual items varied substantially by geography. Polygyny was the most common RC risk factor across six sites (adjusted odds ratio (aOR) range: 1.59-10.76). Increased partner education levels were protective in Kenya and Kano, Nigeria (aOR range: 0.23-0.67). Other assessed correlates differed by site.

CONCLUSIONS

Understanding RC prevalence and behaviors is central to providing woman-centered reproductive care. RC was most strongly correlated with factors at the partner dyad level; future research is needed to unpack the relative contributions of relationship power dynamics versus cultural norms surrounding childbearing. Family planning services must recognize and respond to women's immediate needs to ensure RC does not alter reproductive trajectories, including vulnerability to unintended pregnancy.

Future directions for reproductive coercion and abuse research

BACKGROUND

Reproductive coercion and abuse (RCA) is a form of intimate partner violence (IPV) in which people with the capacity for pregnancy experience coercive behaviors that threaten their reproductive autonomy. Behaviors that constitute RCA include contraceptive control/sabotage, pregnancy pressure, and controlling the outcome of a pregnancy. Several areas of RCA study have emerged: associations with IPV, health outcomes resulting from RCA, and demographic and contextual factors associated with experiencing RCA. Current research in these areas is summarized and placed in a global context, including sexual and gender minority groups, use of RCA (exploring perpetration), RCA interventions, RCA in women with disabilities, and the question of whether people assigned male at birth can be RCA victims.

CONCLUSION

Areas for future exploration include evolving interpretations of pregnancy intention in the setting of fewer options for abortion, RCA in people with disabilities and multiple levels of marginalization, including sexual and gender minorities; intersections between RCA and economic abuse in the context of efforts at economic justice; and community-centered approaches to intervention and prevention.

Pregnancy coercion, correlates, and associated modern contraceptive use within a nationally representative sample of Ethiopian women

Partner-perpetrated pregnancy coercion inhibits women's reproductive autonomy. However, few studies have quantified pregnancy coercion and its effects on women's health within low- and middle-income countries. Among a national sample of Ethiopian women, this study aimed to: (1) assess the prevalence of past-year pregnancy coercion and explore regional differences; (2) identify correlates; (3) examine the relationship between pregnancy coercion and modern contraceptive use. Analyses utilise cross-sectional data from Performance Monitoring for Action (PMA)-Ethiopia, a nationally representative sample of females aged 15-49 conducted from October to November 2019. Past-year pregnancy coercion was assessed via five items and analysed dichotomously and categorically for severity. Among women in need of contraception, bivariate and multivariable logistic regression examined associations between variables of interest, per aim, accounting for sampling weights and clustering by enumeration area. Approximately 20% of Ethiopian women reported past-year pregnancy coercion (11.4% less severe; 8.6% more severe), ranging from 16% in Benishangul-Gumuz to 35% in Dire Dawa. Increasing parity was associated with decreased odds of pregnancy coercion. Among women in need of contraception, experience of pregnancy coercion was associated with a 32% decrease in odds of modern contraceptive use (aOR = 0.68; 95% CI: 0.53-0.89); when disaggregated by severity, odds decreased for most severe pregnancy coercion (aOR = 0.59; 95% CI = 0.41-0.83). Results indicate that partner-perpetrated pregnancy coercion is prevalent across diverse regions of Ethiopia, and most severe forms could interrupt recent gains in contraceptive coverage and progress to sexual and reproductive health and rights. Providers must be aware of potential contraceptive interference and address coercive influences during contraceptive counselling.

Reproductive coercion as a form of family violence against immigrant and refugee women in Australia

Reproductive coercion (RC), generally considered a form of intimate partner violence (IPV), refers to perpetrator behaviours and actions that are intended to interfere with and control the autonomous decision-making of a person regarding their reproductive health. To date there are few studies that document RC as experienced by immigrant and refugee women. In this article, we explore cases of RC as described by women who were part of a larger qualitative study investigating violence against immigrant and refugee women in southern Australia. The study aimed to identify the types of RC detailed in immigrant and refugee women’s narratives, and to illustrate the contexts in which these experiences occurred. Analysis followed Baxter and Jack’s (2008) case study methodology; whereby particular “cases” are used to describe a phenomenon in context. Thirteen women from seven countries described experiences that fit definitions of RC. The cases describe various types of RC including violence during pregnancy with the intent of causing miscarriage, forced abortion, contraception sabotage and forced pregnancy. As well as intimate partners, some women described multiple perpetrators being complicit in their experience of RC, especially in regard to controlling women’s access to, and interactions with health services. More information is needed about immigrant and refugee women’s experiences of RC, and how vulnerability to multi-perpetrator violence affects health service access. In particular knowledge about how multi-perpetrator RC can affect consent processes for women who already face barriers to health care requires attention. Further research is required to address knowledge gaps about appropriate prevention and advocacy work about RC in refugee and migrant communities, and what training is needed for professionals in the family violence sector, women’s health services, women’s organisations, multicultural and ethno-specific services.

Violence against women from partners and other household members during COVID-19 in Burkina Faso and Kenya

Background

Global evidence indicates increases in gender-based violence (GBV) during the COVID-19 pandemic following mitigation measures, such as stay at home orders. Indirect effects of the pandemic, including income loss, strained social support, and closed or inaccessible violence response services, may further exacerbate GBV and undermine help-seeking. In Kenya and Burkina Faso, as in many settings, GBV was prevalent prior to the COVID-19 pandemic. Studies specific to COVID-impact on GBV in Kenya indicate mixed results and there remains a lack of evidence from Burkina Faso. Our study takes a comprehensive lens by addressing both intimate partner violence (IPV) and non-partner household abuse through the COVID-19 pandemic in two priority settings.

Methods

Annual, national cross-sections of women ages 15–49 completed survey data collection in November–December 2020 and December 2020–March 2021; the GBV module was limited to one woman per household [Kenya n = 6715; Burkina n = 4065]. Descriptive statistics, Venn diagrams, and logistic and multinomial regression characterized prevalence of IPV and other household abuse, frequency relative to the COVID-19 pandemic, help-seeking behaviors, and predictors of IPV and household abuse across the socioecological framework.

Results

In both settings, past-year IPV prevalence exceeded non-partner household abuse (Kenya: 23.5%_IPV, 11.0%_household; Burkina Faso: 25.7%_IPV, 16.2%_household). Over half of those affected in each setting did not seek help; those that did turned first to family. Among those with past-year experiences, increased frequency since COVID-19 was noted for IPV (16.0%_{Burkina Faso}; 33.6%_Kenya) and household violence (14.3%_{Burkina Faso}; 26.2%_Kenya). Both context-specific (i.e., financial autonomy in Burkina Faso) and universal (i.e., COVID-related income loss) risk factors emerged.

Conclusion

Past-year IPV and household violence against women in Kenya and Burkina Faso were prevalent, and in some cases, intensified during the COVID-19 pandemic. Across settings, help-seeking from formal services was notably low, likely reflecting shame, blame, and stigmatization identified as barriers in pre-COVID literature. Both primary prevention and survivor-centered support services, including those related to economic empowerment, should be integrated within COVID-recovery efforts, and extended into the post-pandemic period to fully meet women’s safety needs.

Understanding the Link Between Reproductive Coercion and Covert Use of Contraception as a Safety Strategy for Women Experiencing Violence in Nairobi's Urban Informal Settlements

This mixed-methods study examined the relationship between reproductive coercion (RC) and covert contraceptive use among intimate partner violence survivors in Nairobi, Kenya. Quantitative analyses utilize baseline data from the myPlan Kenya trial (n = 321). Purposive in-depth interviews (IDIs) (n = 30) explored women's reproductive safety strategies. Multinomial analyses indicated increased covert use and decreased overt use compared to nonuse, for women experiencing RC; logistic models similarly report increased odds of covert use with RC experience. Qualitative data contextualize women's reasons for use and challenges faced. Integration of reproductive safety strategies into family planning and violence services can improve the safe use of contraception.

Women living with their mothers-in-law

Background

Many studies have documented the impacts mothers-in-law have on daughters-in-law living in the same household, but few have quantified the scale of this co-residence.   This study aims to estimate the proportion of married women living with their mothers-in-law across countries and time. 

Methods

Using household rosters from 250 Demographic and Health Surveys in 75 countries, this paper uses the “relationship to head of household” question to identify households where married women live with their mothers-in-law.  For select countries with large changes, we decompose changes in rates into changes in the age structure of married women and the rate of women living with their mothers-in-law by age.

Results

This paper finds large variation in family structure around the globe, from 1% of married women in Rwanda to 49% in Tajikistan living with their mother-in-law.  Many countries with high co-residence in the 1990s continue to see high and increasing numbers today, especially in Central and Southern Asia, while some North and sub-Saharan African countries experienced substantial declines.  Decomposing changes by age and rates shows that changes in the age structure of married women is not driving changes in co-residence, but rather the rates are changing across age groups. 

Conclusions

These findings show the large variation in women living with their mothers-in-law across the globe.  The authors provide publicly available code and future research ideas to encourage others to further our understanding of the impact of living with her mother-in-law on a woman’s life.

Reproductive coercion and abuse in Australia: what do we need to know?

Reproductive coercion and abuse refers to patterns of controlling and manipulative behaviours used to interfere with a person's reproductive health and decision-making. Unintended pregnancy, forced abortion or continuation of a pregnancy, and sexually transmissible infections all may result from reproductive coercion, which is closely associated with intimate partner and sexual violence. Clinicians providing sexual and reproductive healthcare are in a key position to identify and support those affected. Yet, reproductive coercion and abuse is not currently screened for in most settings and addressing disclosures poses many challenges. This article discusses what reproductive coercion and abuse is, who it affects, how it impacts, and potential strategies to improve identification and response.

How gender norms affect anemia in select villages in rural Odisha, India: A qualitative study

BACKGROUND

In India, 50% of women of reproductive age, compared with 23% of men, have iron deficiency anemia. Extant research focuses on biological, not social, determinants of this disparity.

OBJECTIVES

The aim of this study was to examine how gender norms may affect anemia prevalence among women in rural India.

METHODS

We conducted 16 focus group discussions (N = 124) with women of reproductive age, husbands, and mothers-in-law and 25 key informant interviews in four villages in Odisha, India.

RESULTS

We identified the following themes that help explain how inequitable gender norms exacerbate anemia among women from different castes and tribes: Due to a double burden of work outside the home and completing the majority of unpaid work in the home, women lack time to visit health centers to get tested for anemia and to obtain iron supplements. Women are expected to prioritize the health of their family over their own, thus affecting their access to health care. Women's autonomy to leave the house to seek health care is limited. Men are the primary breadwinners for the family, but often spend their money on alcohol, rather than on iron-rich food for the household. Intra-household food allocation favors men, in-laws, and children, thus women serve their family first, often being left with little food.

CONCLUSION

Anemia reduction interventions need to include examination of the whole social context to successfully increase iron supplement use and iron-rich food intake. Understanding how gender norms contribute to anemia could change the narrative from a biomedical to a social justice issue.

Reproductive Coercion among Intimate Partner Violence Survivors in Nairobi

Reproductive coercion (RC), or partner interference in reproductive decisions, limits women's autonomy. Little is known about RC behaviors and measurement in low- and middle-income countries (LMICs). In this mixed-methods study, we examined the transferability of the US-developed RC Scale to the Kenyan context. Through community-based sampling, recent intimate partner violence (IPV) survivors were recruited from Nairobi's informal settlements. We conducted quantitative analyses (n = 327) to assess the transferability of RC measures via exploratory factor analysis and used descriptive statistics to examine prevalence and continuous metrics. We conducted in-depth interviews (IDIs; n = 30) to contextualize results. Psychometric analyses indicated a two-factor solution comprising pregnancy coercion and condom manipulation (alpha = 0.86). Eighty-two percent of IPV survivors reported experiencing RC (pregnancy coercion = 76.6 percent; condom manipulation = 59.5 percent). IDIs highlighted women's multiple, severe RC experiences; experiences described in IDIs were largely consistent with quantitative findings. We found the RC Scale was transferable to this LMIC context, where IPV survivors face prevalent, severe RC and would benefit from linkage to woman-centered support services.

Socioecological determinants of community resource utilisation among low-income women in Mexico City who experienced male-to-female intimate partner violence

Women who experience intimate partner violence (IPV) face multiple barriers to seeking help from community resources, but little research has examined the impact of ecological influences on community resource utilisation among women living in low- and middle-income countries. The current study investigated individual-, relationship-, family-, and community-level influences on community resource utilisation among Mexican women experiencing IPV. Using baseline data from 950 women in Mexico City enrolled in a clinic-based randomised controlled trial, multilevel regressions were performed to assess associations between socioecological factors and women's community resource utilisation. 41.3% women used at least one resource. At the individual-level, every additional resource that women were aware of, was associated with a 20% increase in the total number of resources used (p < .001). Every additional lethal risk factor was associated with a 5% increase in the total number of resources used (p = .004). At the family-level, women who reported having an in-law encourage IPV used 46% more resources (p < .001). At the community-level, stronger supportive norms around community resource utilisation was associated with a 6% increase in the total number of resources (p = .01). These findings suggest the importance of addressing family and community factors in the broader ecological context of Mexican women's help-seeking behaviours.

Reproductive coercion in Uttar Pradesh, India: Prevalence and associations with partner violence and reproductive health

Increasing modern contraceptive use and gender equity are major foci of the recently ratified Sustainable Development Goals for 2030 and the Government of India. Coercion and sabotage by husbands and in-laws to inhibit women's access, initiation, continuation, and successful use of modern contraception methods (i.e., reproductive coercion) may contribute to low usage rates and unintended pregnancy in India; however, little is known about the extent of this problem. The current study assesses the prevalence of reproductive coercion, both husband and in-law perpetrated, among a large population-based sample. Data were collected from currently married women of reproductive age (15–49 years; N = 1770) across 49 districts of Uttar Pradesh as part of an evaluation of a broad effort to improve the public health system in the state. Dependent variables included modern contraceptive use in the past 12 months, unintended pregnancy, and pregnancy termination. Independent variables included ever experiencing reproductive coercion (RC) by a current husband or in-laws and lifetime experience of physical and sexual intimate partner violence (IPV) by a current husband. Approximately 1 in 8 (12%) women reported ever experiencing RC from their current husbands or in-laws; 42% of these women reported RC by husbands only, 48% reported RC by in-laws only, and 10% reported RC by both husbands and in-laws. Among women experiencing RC, more than one-third (36%) reported that their most recent pregnancy was unintended; these women had 4 to 5 times greater odds of unintended pregnancy and a more than 5 times decreased likelihood of recent use of modern contraceptives than women not experiencing RC, after accounting for effects of demographics and physical and sexual IPV. Scalable and sustainable interventions in both clinical and community settings are needed to reduce RC, a potentially key factor in effective strategies for improving women's reproductive autonomy and health in India and globally.

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1 in 8 women in Uttar Pradesh report reproductive coercion from husbands or in-laws.

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Husbands and in-laws were responsible for RC in similar measure (42% and 48%).

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Experiencing RC related to 4–5x greater odds of recent unintended pregnancy.

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Experiencing RC related to 5x decreased odds of recent contraceptive use.

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Reducing RC is key to improving women's reproductive autonomy and health.

Intimate Partner Violence and the Sexual and Reproductive Health Outcomes of Women in Ghana

Few studies have examined the relationships between intimate partner violence (IPV) and the sexual and reproductive health outcomes of women in sub-Saharan countries in general and Ghana specifically. This study began to fill the gap by investigating whether individual- and community-level IPV influenced unwanted pregnancy and pregnancy loss among women in Ghana. Nationally representative cross-sectional data were collected from 2,289 ever-married women, and multilevel modeling was used to estimate individual- and community-level effects. At the individual level, IPV was significantly associated with unwanted pregnancy and pregnancy loss. Women with experience of both physical and sexual violence were more likely to have reported an unwanted pregnancy and a pregnancy loss. However, only those experiencing sexual violence reported unwanted pregnancies. Similarly, community-level IPV was associated with sexual health outcomes. Respondents in communities with higher levels of sexual violence were significantly more likely to have had unwanted pregnancies. The findings corroborate calls for policy makers to consider IPV a reproductive health issue. They also emphasize the need to move beyond individual-level interventions to consider structural and community contexts when addressing the sexual and reproductive health outcomes of women in Ghana.

Reproductive control by others: means, perpetrators and effects

BACKGROUND

Reproductive control of women by others comprises a wide range of behaviours, from persuasion to pressure such as emotional blackmail, societal or family expectations, through to threats of or actual physical violence. It is defined as behaviours that interfere with women's reproductive autonomy as well as any actions that pressurise or coerce a woman into initiating or terminating a pregnancy METHOD: Narrative review based on a search of medical and social science literature.

RESULTS

Reproductive control by others includes control or coercion over decisions about becoming pregnant and also about continuing or terminating a pregnancy. It can be carried out by intimate partners, the wider family, or as part of criminal behaviour. One form is contraceptive sabotage, which invalidates the consent given to sex. Contraceptive sabotage includes the newly-described behaviour of 'stealthing': the covert removal of a condom during sex. Reproductive control by others is separate from intimate partner violence but there are similarities and the phenomena overlap. Reproductive control by others is reported by as many as one quarter of women attending sexual and reproductive healthcare services. Those treating such women should be familiar with the concept and how to ameliorate its effects. Screening questions for its detection have been developed as well as interventions to reduce its risk.

CONCLUSIONS

Reproductive control by others is common and those working in women's health should be familiar with the concept and with screening tools used to detect it.

Reproductive Coercion: A Systematic Review

Reproductive coercion is a behavior that interferes with the autonomous decision-making of a woman, with regard to reproductive health. It may take the form of birth control sabotage, pregnancy coercion, or controlling the outcome of a pregnancy. The objectives of this article are to address the questions: (1) What is known about reproductive coercion, its prevalence, and correlates? (2) What strategies do women use to preserve their reproductive autonomy when experiencing reproductive coercion? (3) What interventions are effective to decrease reproductive coercion? In this review of 27 research studies, 12 contained findings regarding the general phenomenon of reproductive coercion and 19 contained findings about at least one component of reproductive coercion. Additionally, 11 studies contained findings related to the intersection of intimate partner violence (IPV) and reproductive coercion, 6 presented data on strategies women use to resist reproductive coercion, and 3 included intervention data. Variation in measurement makes synthesis of prevalence and correlate data challenging. The reviewed literature presents reproductive coercion as a phenomenon that disproportionately affects women experiencing concurrent IPV, women of lower socioeconomic status, single women, and African American, Latina and multiracial women. Women who experience reproductive coercion were found to present frequently for certain health services. Most data on reproductive coercion are descriptive, and there is need for further research to examine the co-occurrence with related phenomena such as IPV and unintended pregnancy. More research is also needed on the strategies women use to resist reproductive coercion as well as interventions aimed at survivors and perpetrators of reproductive coercion and health-care providers who encounter them.

Intimate partner violence and constraints to reproductive autonomy and reproductive health among women seeking abortion services in Bangladesh

OBJECTIVE

To understand intersections between intimate partner violence (IPV) and other constraints to women's reproductive autonomy, and the influence of IPV on reproductive health.

METHODS

A secondary analysis examined cross-sectional data from a facility-based sample of women seeking abortion care (for spontaneous or induced abortion) between March 1 and October 31, 2013. Women aged 18-49 years, who received abortion services and selected a short-acting contraceptive method or no contraception completed an interviewer-administered survey after treatment. Adjusted prevalence ratios (aPRs) were calculated for associations between IPV experience and potential constraints to reproductive autonomy and health outcomes.

RESULTS

There were 457 participants included in the present analysis and 118 (25.8%) had experienced IPV in the preceding year. IPV was associated with discordance in fertility intentions with husbands/partners and in-laws, with in-law opposition to contraception, with perceived religious prohibition of contraception, and with presenting unaccompanied (all P<0.05). IPV was also associated with receiving post-abortion care after an induced abortion compared with accessing legal menstrual regulation, and with the use of medication abortion compared with manual vacuum aspiration (both P<0.05).

CONCLUSION

Intimate partner violence was associated with additional constraints on reproductive autonomy from husbands/partners, in-laws, and religious communities. Seeking induced abortion unaccompanied and using medication abortion could be strategies to access abortion covertly among women experiencing IPV. Ensuring women's reproductive freedom requires addressing IPV and related constraints.

A Systematic Review of Reproductive Coercion in International Settings

Reproductive coercion is behavior that interferes with a woman's autonomous reproductive decision-making. It may take the form of birth control sabotage, pregnancy coercion, or controlling the outcome of a pregnancy. Perpetrators may be partners, a partner's family, or the woman's family. This article reviews the literature on reproductive coercion in international settings. In this review of 10 research studies, findings are presented on prevalence and type of reproductive coercion, associated factors, specific tactics, relationship with intimate partner violence and domestic violence (in-laws particularly), and implications for women's reproductive health. Findings highlight reproductive coercion as a subset of intimate partner violence that is poorly understood, especially in international settings. More research is needed on protective factors, how interventions can capitalize on protective factors, and the strategies women use to resist reproductive coercion. Policy implications and recommendations are discussed with particular attention to issues related to diverse social and cultural environments.

Intimate partner violence and reproductive coercion: global barriers to women's reproductive control

Jay Silverman and Anita Raj discuss the policies and interventions required to address the range of poor reproductive outcomes for women and adolescents, including loss of reproductive control, associated with intimate partner violence.

Please see later in the article for the Editors' Summary

Mental health impacts of reproductive coercion among women in Côte d'Ivoire

OBJECTIVE

To assess the independent associations of partner-perpetrated reproductive coercion, intimate partner violence (IPV), in-law reproductive coercion, and in-law abuse with recent probable post-traumatic stress disorder (PTSD), and to test their relationship with PTSD symptoms when controlling for the other types of abuse among partnered women in rural Côte d'Ivoire.

METHODS

Cross-sectional analyses were conducted using logistic generalized estimating equations, which accounted for village-level clustering. Data were drawn from baseline data from a randomized controlled trial among 24 villages in rural Côte d'Ivoire (n=953 partnered women). Three adjusted models were used to test associations of reproductive coercion and abuse with probable PTSD.

RESULTS

Partner-perpetrated reproductive coercion was experienced by 176 (18.5%) women. In model 3, which accounted for the co-occurrence of abuses, partner-perpetrated reproductive coercion (odds ratio [OR] 2.3; 95% confidence interval [CI], 1.4-3.9) and partner-perpetrated IPV (OR 1.7; 95% CI, 1.1-2.7) were the most significant predictors of past-week probable PTSD (P<0.05).

CONCLUSION

Reproductive coercion may be a significant contributor to poor mental health. The mental health impacts of reproductive coercion and IPV should be considered within psychosocial programming for rural Ivorian communities to address the full range of traumatic experiences that may have been experienced by women.

Recent abuse from in-laws and associations with adverse experiences during the crisis among rural Ivorian women: extended families as part of the ecological model

Violence against women in the aftermath of conflict represents a growing area of concern. However, little is known about violence perpetrated by a woman's in-laws and how these experiences may be related to adverse experiences during a crisis. Therefore, guided by the ecological model, the objectives of the following analysis were to (1) document adverse experiences during the crisis among rural Ivorian women and (2) investigate the association between such experiences and abuse perpetrated by partners' extended families, among a sample of women residing in rural Côte d'Ivoire. Utilising data from a baseline survey conducted in 2010, we generated descriptive statistics and used generalised estimating equations to assess the relationships of interest. Women whose family was victimised during the crisis had 1.7 times the odds of reporting past-year in-law abuse compared to those women whose families did not experience such adversity (95% CI: 1.1-2.4), and women who experienced a personal form of adversity had twice the odds of reporting past-year in-law abuse compared to women who did not report victimisation (95% CI: 1.2-3.2). Being forced to flee was not statistically associated with in-law abuse. Findings underscore the importance of addressing in-law abuse in order to promote women's health in post-conflict settings.