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Intimate partner violence IPV is a global public health problem that has substantial consequences on the physical, mental, sexual and reproductive health of women. Two waves of Bangladesh Demographic and Health Survey data were analyzed using multivariate regression. Outcome variables were a set of reproductive healthcare services, namely contraception use, modern contraception use, antenatal visit by skilled health professionals SHPdelivery in healthcare facilities, delivery by SHP and postnatal check up by SHP. There is a gradient in the relationship between of healthcare services accessed and of situations justified for beating wife.

Women who strongly reject the justification of wife beating were more likely than those who reject that weakly to report contraception use, antenatal care by SHP, delivery in healthcare facilities, delivery care by SHP, and postnatal care by SHP. Citation: Khan MN, Islam MM Women's attitude towards wife-beating and its relationship with reproductive healthcare seeking behavior: A countrywide population survey in Bangladesh. This is an open access article distributed under the terms of the Creative Commons Attributionwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Competing interests: The authors have declared that no competing interests exist. Intimate partner violence IPV is a well-recognized public health problem [ 12 ]. Women who are victims of IPV have increased risk of unintended pregnancy, multiple abortions and reduced sexual autonomy [ 3 ]. Additionally, IPV during pregnancy may ificantly increase the risk of preterm delivery, low birth weight infant and neonatal death [ 3 — 5 ].

IPV is also associated with mental health problems such as depression, suicide, posttraumatic stress disorder PTSD [ 67 ] and other adverse health outcomes including chronic fear and cardiac problems [ 8 ]. Primary healthcare has always been considered important, aiming to provide a safe environment where abused women can confidentially disclose experiences of violence and receive care for adverse health outcomes caused by violence [ 9 ]. This care is important particularly for pregnant women. For instance, it is generally believed that a man has the right to assert power over a woman and correct female behavior [ 1314 ] using physically punitive measures such as beating [ 15 ].

A direct relationship exists between the tolerant attitudes toward violence against women and the actual occurrence of violence against women [ 20 — 22 ]. Therefore, we hypothesize that women with a tolerant attitude towards violence may use reproductive healthcare services less than those who do not hold such an attitude.

We used aggregate data of two waves of BDHS, collected in and The survey was based on a two-stage stratified sample of households whereby enumeration areas clusters were first drawn from the national population and housing census sampling frame conducted in by Bangladesh Bureau of Statistics.

In the first stage of sampling, primary sampling units were selected with probability of selection proportional to the unit size. In the second stage, 30 households were selected within each primary sampling unit by systematic random sampling.

Further details of sampling de and data collection approach of BDHS can be found elsewhere [ 1116 ]. In two waves, a total of 35, ever-married women were interviewed. The questions on domestic violence were administered only on one ever married woman age 15—49 years per household. Selecting only one person to respond to IPV-related questions protected the privacy of the person and helped ensure the other respondents in the household were not aware of the types of questions that the selected respondent was asked.

If privacy could not be ensured, the interviewers were instructed to skip the module. If there was more than one eligible women in the household, the respondent was selected randomly through a specially deed simple selection procedure based on the Kish Grid [ 25 ]. Using this method, a total of 16, Among these women, a total of 9, reported at least one birth within three years preceding the survey and were considered eligible for this study.

The survey protocol was reviewed and approved by the National Research Ethics Committee in Bangladesh. Because the existence of a ed consent form can provide a risk in itself for the abused person, only oral informed consent was obtained from the respondents. The ethics committee approved this consent procedure. All data were fully anonymized by the BDHS authority prior to making them available. Five questions are: 1 if she goes out without telling her husband; 2 if she argues with her husband; 3 if she neglects the children; 4 if she refuses to have sex with her husband; and 5 if she burns food.

Composite scores were computed for each respondent based on the average of responses to the five items mentioned above. We then split the mean score into three : i reject weakly score 1. Therefore, a high mean score indicates a weak rejection i. The utilization of a range of reproductive healthcare services were the outcome variables. They were, namely i the types of contraception methods respondents used traditional vs modern ; ii of times they received antenatal care; iii types of services respondents accessed for antenatal and postnatal care; iv place of delivery home or healthcare facility ; and v whether the respondents received healthcare from skilled health professionals SHPs during their recent delivery.

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Traditional contraception includes periodic abstinence, withdrawal and folk methods while modern contraception includes pill, female- and male-sterilization, intrauterine devices, injectable, implants, male and female condom, diaphragm, and emergency contraception. Descriptive statistics were used to estimate the demographic characteristics of participants and their attitudes towards wife-beating in particular circumstances.

To examine the relationship of these attitudes with healthcare seeking and or usage behavior, we estimated both unadjusted and adjusted associations using multivariate logistic regression. A range of socio-demographic covariates that were found important in the literature and could be consistently measured in two waves of survey were included in multivariate models.

The variables were, namely the maternal age at birth, place of residence urban, ruralregion of residence seven divisions: Barisal, Dhaka, Chittagong, Khulna, Rajshahi, Rangpur, Sylhetwealth quintile poorest, poorer middle, richer, richestyears of education for women and their husbands, and the survey years. In BDHS, individuals were nested in households, and households were nested in communities. Thus, individuals in the same household and households in the same community were strongly clustered.

Statistical software Stata version 15 StataCorp. A total of 9, women who responded the questions on perception regarding wife-beating and gave at least one live birth within three years preceding the survey were included in this study. The shares of and survey wave were There were no ificant differences in socio-demographic characteristics between women who did and did not respond to the questions about wife-beating.

The mean age of respondents was 26 years, mean years of schooling was approximately six years. However, the proportions of women who weakly rejected several causes of beating by husband were not consistent across regions Fig 1. The percentages of women who believed beating is justified are presented in Table 1 and Fig 2.

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Around one-fourth of the respondents reported they received more than four antenatal visits Almost half There remains regional variation in utilization of reproductive healthcare for each of these services. There is a gradient in the relationship between of services accessed and of reasons justified for wife-beating Fig 3.

A higher of women who reported no justification of beating accessed healthcare services than women who justified one or more reasons. This gradient is relatively linear for participants who justified three or less reasons and slightly convoluted for those who justified four or more reasons.

Across three of attitude on beating i. The relationship between selected demographic variables and healthcare seeking behaviors are presented in Table 2. Educational status of women and their husbands, and economic status of the household had a ificantly positive association with the utilization of healthcare services by the participants. Urban women were more likely than rural women to report using all except one of the healthcare services.

Women who reported moderate and strong rejection towards wife-beating were 1. Additionally, women who strongly rejected the justification of wife beating were more likely to report accessing healthcare than those who either rejected moderately or weakly. For instance, women who rejected this abuse moderately and strongly were 1. Compared to the women who rejected weakly, the odds of using a health facility during delivery was 1. This relationship was elevated aOR, 1.

Compared to the weakly rejecting group, strong rejecters were 1.

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These were elevated for the respondents who moderately rejected the reasons for wife-beating. Noticeably, this abuse or the proxy is a barrier to accessing several forms of essential healthcare that are likely to impact on health and well-being of participants and their children. However, this is a delicate issue, which demands careful intervention. Therefore, the gradual development of social momentum in opposition to spousal abuse is crucial. Over the recent decades violence against women has shifted ificantly from being considered a private or family problem to being recognized as a social and public health concern with serious consequences for health and wellbeing of the victims [ 2829 ].

Adverse health impact of abused women was reported by a of studies from various international settings [ 30 — 33 ]. The findings from this study now adds evidence to the existing body of literature that women who justify reasons for spousal abuse may also suffer from similar adverse health outcomes, as they access necessary reproductive care much less than others. We found geographical variation in our —both in terms of the extent to which abuse is justified and healthcare utilization. A of studies also consistently reported spatial variation in the prevalence of domestic violence [ 34 ] and the acceptance of IPV within the marriage [ 35 ].

We also found variation between urban and rural areas. This spatial variation is likely due to the variation across regions in terms of social norms and practices, which are deeply rooted and strongly influenced by and intermingled with a range of factors such as education, economic status, employment, culture, religion, to name a few [ 3637 ].

When considered from a policy perspective, this variation suggests a necessity to implement geographically tailored interventions. This study does not examine the underlying causes of justifying wife-beating and their association with reproductive healthcare seeking behavior. Further studies are needed for identifying the causal pathways.

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Some information on this issue, however, is available in the existing literature. For instance, Vung et al [ 38 ] identified a range of factors associated with IPV and categorized them into four main groups: individual, relationship, community and societal. This, and a few other studies, report that IPV is likely to pass through generations [ 38 — 40 ]. Women who witness partner violence during their childhood are more likely to report experiencing IPV in their own adult life, and they also seem to hold more tolerant attitudes towards violence [ 38 ].

The literature suggests that violence is frequently used to resolve a crisis of male identity. Risk of violence is greatest in societies where the use of violence is socially accepted [ 41 ]. Women who are more empowered educationally, economically, and socially are most protected, but below this high level the relation between empowerment and risk of violence is known to be non-linear [ 41 ].

A relatively low rate of healthcare utilization among women who justified several reasons for wife-beating could be explained by the fact that this subgroup lacks empowerment and the sense of entitlement. Perhaps a good example to support this assumption is our finding about the higher prevalence of contraception use among the women who moderately or strongly reject the reasons for wife-beating. This ability is crucial for making a decision of seeking and or utilizing healthcare. There is a negative trend in utilization of healthcare services across three of attitude on abuse i.

This trend has important public health implications. Most of our public health interventions often pay considerable importance towards making services available. Although availability is an important aspect, some studies suggest available services may not be accessed by women who lack self-esteem or are subject to societal dominance of gender norms [ 43 — 45 ].

Thus, eradication of this norm and primary prevention of violence are essential. However, in reality, any effort to this end is often over-shadowed by the importance of the large of programs that, understandably, seek to deal with the immediate and numerous consequences of violence [ 46 ]. In the adjusted models, some socio-economic factors such as educational levels of women and their husbands, economic status of the household and geographical locations were found to be ificantly associated with the level of healthcare utilization. This observation is mostly consistent with the findings of studies in Bangladesh [ 47 — 49 ] and other developing countries [ 5051 ].

Formal education, economic status and living environment—all are intertwined and an improvement in any of these factors are likely to empower women and their access to basic healthcare services. Although this improvement needs multifaceted endeavors from all fronts, from the policy perspective perhaps a special focus on ensuring longer years of formal education for women is the most important and achievable way forward [ 5253 ]. Our study has several strengths and some limitations.

We used the two most recent nationally representative datasets, which yielded a large sample collected from the entire country.

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Furthermore, we adjusted our models for a wide range of confounders and this enhanced the reliability of our findings. It is not unlikely that some women hold a poor attitude towards abuse although they are not abused by their husbands. This study examined cross-sectional data, therefore, the relationship is correlational only.

Lastly, despite taking precautionary measures to protect privacy, it is still possible that some women did not disclose their true attitudes towards wife-beating. Moreover, utilization of healthcare is subject to the availability of and accessibility to services. One-third of the women justified hitting or beating by their husband in particular circumstances. This attitude towards violence was found to be a ificant factor for the utilization of basic healthcare services. Women who strongly rejected the justification of wife-beating were more likely to report the utilization of basic healthcare services than women who rejected that moderately or poorly.

Although this observed relationship is co-relational only, this has important policy implications. Browse Subject Areas?

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