Objective

The objective was to examine postpartum contraception utilization among Indian women seeking immunization for their infants in three low-income communities in Mumbai, India.

Study design

We conducted a cross-sectional questionnaire of low-income postpartum women seeking immunization for their infants at three large urban health centers in Mumbai. Contraceptive utilization data were collected as part of a larger study focused on the impact of postpartum domestic violence on maternal and infant health. Descriptive, bivariate and multivariate analyses were conducted to describe and identify predictors of postpartum contraceptive utilization.

Results

Postpartum women aged 17-45 years (N=1049) completed the survey; 44.5% (n=467) reported resuming sexual relations with their husbands. Among these women, the majority (65.3%; n=305) reported not currently using contraception. In multivariate analyses, women who did not discuss postpartum family planning with their husbands, had not used contraception previous to the recent birth, and had experienced physical violence or forced sex were more likely to not use postpartum contraception (adjusted odds ratios=1.47-1.77). Among the 162 women using contraception, the most common time to initiation of contraception was 5 weeks postpartum, and the most common method used was condoms 77.8% (n=126).

Conclusion

Contraception nonuse was common among urban, low-income postpartum women in India. This study highlights the importance of developing interventions to increase use of highly effective contraceptive methods postpartum, and that spousal violence and lack of marital communication may present barriers to postpartum contraception utilization. Infant immunization may represent an opportunity for provision of contraceptives and contraceptive counseling.

Implications

This original research study is a unique contribution to the literature because it presents data regarding the nonuse of postpartum contraception among women seeking immunizations for their infants in urban centers in a developing country. It also reveals barriers to not using postpartum contraception and provides data for future interventions.

This study involved evaluation of the short-term impact of the RHANI Wives HIV intervention among wives at risk for HIV from husbands in Mumbai, India. A two-armed cluster RCT was conducted with 220 women surveyed on marital sex at baseline and 4-5 month follow-up. RHANI Wives was a multisession intervention focused on safer sex, marital communication, gender inequities and violence; control participants received basic HIV prevention education. Generalized linear mixed models were conducted to assess program impact, with cluster as a random effect and with time, treatment group, and the time by treatment interaction as fixed effects. A significant time by treatment effect on proportion of unprotected sex with husband (p = 0.01) was observed, and the rate of unprotected sex for intervention participants was lower than that of control participants at follow-up (RR = 0.83, 95 % CI = 0.75, 0.93). RHANI Wives is a promising model for women at risk for HIV from husbands.

Husbands' alcohol use has been associated with family-level stress and intimate partner violence (IPV) against women in India. Joint family systems are common in India and IPV often co-occurs with non-violent family maltreatment of wives (e.g., nutritional deprivation, deprivation of sleep, blocking access to health care). Alcohol use increases for some parents following the birth of a child. This study examined 1,038 postpartum women's reports of their husbands' alcohol use and their own experiences of IPV (by husband) and non-violent maltreatment from husbands and/or in-laws. We analyzed cross-sectional, quantitative data collected in 2008, from women (ages 15-35) seeking immunizations for their infants <6 months at three large urban health centers in Mumbai, India. Crude and adjusted logistic regression models estimated associations between the independent variable (husbands' past month use of alcohol) and two dependent variables (postpartum IPV and maltreatment). Overall, 15% of husbands used alcohol, ranging from daily drinkers (10%) to those who drank one to two times per week (54%). Prevalence of postpartum IPV and family maltreatment was 18% and 42%, respectively. Prevalence of IPV among women married to alcohol users was 27%. Most abused women's husbands always (27%) or sometimes (37%) drank during violent episodes. Risk for IPV increased with a man's increasing frequency of consumption. Women who lived with a husband who drank alcohol, relative to non-drinkers, were more likely to report postpartum IPV, aOR = 2.0, 95% confidence interval (CI) = [1.3, 3.1]. Husbands' drinking was marginally associated with increased risk for family maltreatment, aOR = 1.4, 95% CI = [1.0, 2.1]. Our findings suggest that men's alcohol use is an important risk factor for postpartum IPV and maltreatment. Targeted services for Indian women contending with these issues are implicated. Postpartum care offers an ideal opportunity to screen for IPV, household maltreatment, and other health risks, such as husband's use of alcohol. There is need to scale up proven successful interventions for reducing men's alcohol use and design strategies that provide at-risk women protection from alcohol-related IPV.

Husbands' alcohol use has been associated with family-level stress and intimate partner violence (IPV) against women in India. Joint family systems are common in India and IPV often co-occurs with non-violent family maltreatment of wives (e.g., nutritional deprivation, deprivation of sleep, blocking access to health care). Alcohol use increases for some parents following the birth of a child. This study examined 1,038 postpartum women's reports of their husbands' alcohol use and their own experiences of IPV (by husband) and non-violent maltreatment from husbands and/or in-laws. We analyzed cross-sectional, quantitative data collected in 2008, from women (ages 15-35) seeking immunizations for their infants <6 months at three large urban health centers in Mumbai, India. Crude and adjusted logistic regression models estimated associations between the independent variable (husbands' past month use of alcohol) and two dependent variables (postpartum IPV and maltreatment). Overall, 15% of husbands used alcohol, ranging from daily drinkers (10%) to those who drank one to two times per week (54%). Prevalence of postpartum IPV and family maltreatment was 18% and 42%, respectively. Prevalence of IPV among women married to alcohol users was 27%. Most abused women's husbands always (27%) or sometimes (37%) drank during violent episodes. Risk for IPV increased with a man's increasing frequency of consumption. Women who lived with a husband who drank alcohol, relative to non-drinkers, were more likely to report postpartum IPV, aOR = 2.0, 95% confidence interval (CI) = [1.3, 3.1]. Husbands' drinking was marginally associated with increased risk for family maltreatment, aOR = 1.4, 95% CI = [1.0, 2.1]. Our findings suggest that men's alcohol use is an important risk factor for postpartum IPV and maltreatment. Targeted services for Indian women contending with these issues are implicated. Postpartum care offers an ideal opportunity to screen for IPV, household maltreatment, and other health risks, such as husband's use of alcohol. There is need to scale up proven successful interventions for reducing men's alcohol use and design strategies that provide at-risk women protection from alcohol-related IPV.

Objectives

To determine the prevalence of non-violent, gender-based forms of maltreatment of women by husbands and in-laws [i.e., gender-based household maltreatment (GBHM)] during pregnancy and postpartum; to clarify the role of GBHM in compromising infant health, and whether this role extends beyond that previously observed for intimate partner violence (IPV).

Methods

Cross-sectional, quantitative data were collected from women (ages 15-35) seeking immunizations for their infants <6 months of age (N = 1061) in urban health centers in Mumbai, India. Logistic regression models were constructed to assess associations between maternal abuse (perinatal IPV, in-law violence and GBHM) and recent infant morbidity (diarrhea, respiratory distress, fever, colic and vomiting).

Results

More than one in four women (28.4%) reported IPV during their recent pregnancy and/or during the postpartum period, 2.6% reported perinatal violence from in-laws, and 49.0% reported one or more forms of perinatal GBHM. In adjusted regression models that included all forms of family violence and maltreatment, perinatal GBHM remained significantly associated with infant morbidity (AORs 1.4-1.9); perinatal IPV and in-law violence ceased to predict infant morbidity in models including GBHM.

Conclusions

Findings indicate that non-violent expressions of gender inequity (e.g., nutritional deprivation, deprivation of sleep, blocking access to health care during pregnancy) are more strongly associated with poor infant health than physical or sexual violence from husbands or in-laws in urban India. These results strongly suggest the need to expand the conception of gender inequities beyond IPV to include non-violent forms of gendered mistreatment in considering their impact on infant health.

Background

Intimate partner violence (IPV) victimization is linked to a broad range of negative maternal health outcomes. However, it is unclear whether IPV is directly related to poor maternal outcomes or whether IPV is a marker for other forms of chronic, mundane maltreatment of women that stem from the culture of gender inequity that also gives rise to IPV. To determine the prevalence of non-violent forms of gender-based household maltreatment by husbands and in-laws (GBHM), and violence from in-laws (ILV) and husbands (IPV) against women during the peripregnancy period (during and in the year prior to pregnancy); to assess relative associations of GBHM, ILV and IPV with maternal health.

Methods

Cross-sectional data were collected from women <6 months postpartum (n = 1,039, ages 15-35 years) seeking child immunization in Mumbai, India. Associations of IPV, ILV and GBHM during the peripregnancy period with maternal health (prenatal care in first trimester, no weight gain, pain during intercourse, high blood pressure, vaginal bleeding, premature rupture of membranes, premature birth) were evaluated.

Results

One in three women (34.0 %) reported IPV, 4.8 % reported ILV, and 48.5 % reported GBHM during the peripregnancy period. After adjusting for other forms of abuse, IPV related to pain during intercourse (AOR = 1.79); ILV related to not receiving first trimester antenatal care (AOR = 0.49), and GBHM remained associated with premature rupture of membranes (AOR = 2.28), pain during intercourse (AOR = 1.60), and vaginal bleeding (AOR = 1.80).

Conclusion

After adjusting for ILV and IPV, peripregnancy GBHM remained significantly associated with multiple forms of maternal morbidity, suggesting that GBHM is a prevalent and reliable indicator of maternal health risk.