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Domestic Violence During Pregnancy in India

Meerambika Mahapatro, R.N. Gupta, Vinay Gupta and A.S. Kundu J Interpers Violence published online 30 January 2011 DOI: 10.1177/0886260510390948 The online version of this article can be found at: http://jiv.sagepub.com/content/early/2011/01/09/0886260510390948

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Article

Domestic Violence During Pregnancy in India

Meerambika Mahapatro, PhD1, 2, R. N. Gupta, PhD1, Vinay Gupta1, and A. S. Kundu, PhD1

Journal of Interpersonal Violence XX(X) 118 The Author(s) 2011 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260510390948 http://jiv.sagepub.com

Abstract Domestic violence can result in many negative health consequences for womens health and well-being. Studies on domestic violence illustrate that abused women in various settings had increased health problems such as injury, chronic pain, gastrointestinal, and gynecological signs including sexually transmitted diseases, depression, and posttraumatic stress disorder. This article tries to understand the association between domestic violence and pregnancy outcomes and other health consequences. The study was carried out in all the six zones of India that is, northern, southern, eastern, western, central, and northeast zones. The study design was conceived as an analytical cross sectional study with multicenter approach. Multistage sampling and then probability proportion to size (PPS) sampling were done. A total of 18 states were taken for the study with a total sample of 14,507 married women and 14,108 married men. Married men were considered from the neighboring villages to understand mens perspective.To understand the situation, women were interviewed using semistructured questionnaire as well as qualitative data like FGD and case studies. The result shows that domestic violence occurs during pregnancy across six zones. The situations become worse for women if her husband or family perceived the pregnancy to be a female child and there is a demand for male child. It has major health implications in accessing and utilizing antenatal care and immunization.
1 2

National Institute of Health & Family Welfare, New Delhi, India Indian Council for Medical Research, Ansari Nagar, New Delhi

Corresponding Author: Meerambika Mahapatro, PhD, Indian Council for Medical Research, National Institute of Health & Family Welfare, Baba Ganganath Marg Munirka, New Delhi, India 110067 Email: meerambika@rediffmail.com
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Keywords domestic violence, risk factor, reproductive health, zone

Introduction
Studies have shown that domestic violence contributes to number of chronic health problems and often limits the ability of women to manage themselves. Women are more neglected and health care is deprioritized during pregnancy, delivery, and even after delivery. Negligence toward health care and nutrition is more, therefore, if a girl child was born to a woman. Studies reveal that domestic violence has an association with miscarriage, stillbirth, preterm labor, birth fetal injury, and death as well as low-weight birth baby and increased the risk of infant and under-5 mortality (Bacchus, Bewley, & Mczey, 2001; Gissler, Kauppila, Merilinen, Toukomaa, & Hemminki, 1997; Kajsa et al., 2003; McFarlane, Parker, & Soeken, 1996; Reardon et al., 2002). Many women are coerced, pressurized or battered to submit to unwanted abortions by men who were opposing to birth (Gissler, Berg, Bouvier-Colle, Buekens, 2005). These abused women are less likely to seek prenatal care and more likely to give birth to low-weight babies (Heise, Raikes, Watts, & Zwi, 1994). Studies, mostly in high-income countries have shown that physical violence against pregnant women has increased the risk of preterm delivery, and low-birth weight of offspring, total distress or death (Barenson, Wiemann, Wilkinson, Jones, & Anderson, 1994; Connolly, Katz, Bash, McMahon, & Hansen, 1997). Homicide is the leading cause of death among pregnant women (Gissler et al., 1997, Reardon et al., 2002). Among women of reproductive age (15-44 years), gender violence account for more deaths and disability than malaria, cancer, traffic injuries or war, put together (World Health Organisations, 2000). The frequency of abuse during pregnancy was reportedly equal to or greater than that of other complications of pregnancy that were major elements of prenatal care (Campbell, 1995). Violence during pregnancy can cause a threat to the life and health of the mother and fetus (Jejeebhoy, 1998) and in 3% to 13% of pregnancies in many studies from around the world was associated with detrimental outcomes to mothers and infants (Campbell, 2002). A study from India reported that moderate to severe spousal physical violence during pregnancy to be 13% (Peedicayil et al., 2004). There has been area specific small studies in India reports 16% of all deaths during pregnancy resulted from partner violence in Pune (Gantra, Coyaji, & Rao, 1998); every

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Mahapatro et al.

third household in Punjab has acknowledged wife beating (Santhanam, 2002); the second and third highest numbers of cases of cruelty by husbands and relatives have been reported from south and north Pargana districts of West Bengal and abuse was recurrent in 92% of women in Nagpur (Purwar et al., 2005; Womens Project in Nagpur India, n.d.). Abused women are twice as likely to begin antenatal care after 32 weeks of gestation as compared with nonabused women (Purwar et al., 1999). The violence against women in South Asia begins before birth. It is estimated that 50 million women are missing in India either through sex selective abortions, female infanticide or neglect (Oxfam, 2004). Community-based microstudies are available (Hassan et al., 2004; Jeyaseelan et al., 2007) from northern (Jejeebhoy, 1998; Stephenson, Koenig, & Ahmed, 2006), southern (Jejeebhoy, 1998; Krishnan, 2005) and western states (Visaria, 2000) of India, there is considerable variation across the states in the prevalence of domestic violence (NFHS-3, International Institute for Population Sciences (IIPS) and ORC Macro, 2007). The issue of domestic violence and its the underlying social determinants of domestic violence and its importance for reproductive health in developing countries remains limited especially in the context of India. However, in current Indian literature domestic violence is not covered in a holistic perspective. Most of the literature focuses primarily on linkages between socialization of women into subordinate position, male dominance and domestic violence (Heise et al., 1994). This article is prepared based on the country wide community based study on a large population offering additional information on the prevalence of all these factors are evolving phenomena in the context of India

Study Goal
This study had three primary goals as follows: 1. To study the prevalence of different forms of domestic violence during pregnancy and its impact on womens reproductive health in a heterogeneous society like India with culture defined norms. 2. To measure the pressure of delivering a male child or husband/family member perceiving a male child during the pregnancy period of the women creates psychological health problem confronting violence within the home and influences pregnancy outcome. 3. To study the impact of domestic violence on womens health in broader sense and in particular accessing or utilizing antenatal care including immunization, food intake, and rest during pregnancy.

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Method
Study design. The study design was conceived as an analytical cross sectional study. A population-based multicenter approach was adopted. The research was conducted in the year 2004-2007. Population. Inclusion criteria for the study was married women in the age group between 15 and 35 years were the eligible study sample. And the exclusion criteria was unmarried; widow, separated women, and married women above 35 age group were not considered. Married women in this age group were considered because they would have dynamism as well as decisionmaking power to make change in their life style. Corresponding to the women sample, married men aged below 50 years were selected.

Sampling Frame
The study was carried out in all the six zones that is, northern, southern, eastern, western, central, and northeast zones to have a wider representation of the area/zone. Three states from each zone were selected based on the high, medium, and low prevalence of domestic violence reported by National Family Health Survey-2 (NFHS-2, International Institute for Population Sciences (IIPS) and ORC Macro, 2000). A total of 18 states were selected. They are Delhi, Haryana, Uttaranchal from north; Orissa, West Bengal, and Jharkhand from east; Tamil Nadu, Karnataka, and Kerala in south; Maharastra, Goa, and Gujarat in west; Madhya Pradesh, Uttar Pradesh, and Chhattisgarh in central; and Assam, Meghalaya, and Sikkim in northeast. Rural and urban areas were considered for the study in 70:30 ratios. For rural area two districts from each states were randomly selected. At the second stage of sampling, two blocks were randomly selected by using the information from 2001 census and when it was not available 1991 census handbook was used for sampling of blocks and villages. To select the married woman, multilevel sampling was done. Later a systematic sampling procedure was followed for households. Due to the fairly large sample allocation in each village attempts were made to cover all the households in a systematic manner. In the similar way from the neighboring village/urban pocket to avoid risk to the women, married men were selected.

Sample Size
A multistage sampling was done at each level to find out the sample size. Several studies have shown that the risk of bad obstetric outcome of pregnancy expected to be double with women subjected to abuse or violence. The bad

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obstetric outcome of pregnancy was reported to be 8% and women facing domestic violence double the risk (OR = 2) of bad obstetric outcome of pregnancy. A sample of about 375 of married women per zone were considered adequate for the study ( = .05 and power = 0.80) which included a margin of 10% nonresponse. A total of 14,507 married women and 14,108 married men were studied from all 18 states of India. The sample size for each of the selected state within the zone was determined based on the prevalence rate of domestic violence by probability proportion to size was used to get the appropriate number of respondents. Instruments. Considering the sensitiveness of the issue and maintaining the confidentiality interview-schedule method using semistructured questionnaire, focus group discussion and case study were carried out. The semistructure questionnaire used for interviewing women was focused on socioeconomic variables, empowerment indicators, violence experience, treatment, and support received by the battered woman and coping strategy. It helped to understand physical, psychological, sexual, and phonetic expression of the victims of violence and experience of violence during their life-time as well as during the last 12 months. In the traditional masculine society like India, to construct individual experiences of violence, more open-ended cultural space for dialogue was required. Pilot testing of instrument. In the pilot study, the interview schedule was applied in two study areas to 90 respondents in Ahmedabad (Gujarat) and 60 in Pillkua (Uttar Pradesh). The information collected was incorporated and the response range was prepared for the open-ended questions. After finalization of the schedule by the coordinating center, the schedule was again pretested by the six participating center and modifications were included to make a standard schedule. These semistructured questionnaire was developed in English and translated into the languages of the study states. Each state has its own dialects. Therefore, the questionnaire was translated in the local colloquial languages and back translated to ensure semantic and content validity. The translated questionnaires were further reviewed for linguistic reliability and correctness, clarity and flow of questions by the principal investigators (PIs) and the staff of each center. Training of interviewers. After detail discussion with the PIs of the six participating center, specific training was conducted for the interviewer by the PIs. Each interviewer applied the schedules to the proxy respondent in their area. Informed consent/ethical consent. Since questions and probes on certain issues were personal and sensitive at times, hence prior to access such information the respondents were duly informed about the details of the study and replies to any of their questions provided. After they revealed verbally their

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willingness to participate in the study, their informed consent was taken using appropriate method/form. Considering the issue sensitive, confidentiality of respondents in interview-schedule was maintained to minimize potential risks to respondents associated with participating in the study. Interviews were conducted by highly trained female interviewers in complete privacy. Completed questionnaires were maintained in secure facilities, and interview schedules were coded with the respondents study identification numbers. As the study was carried out by different centers/institutes, institutional ethical clearance was obtained by each of the concerned PIs from their respective ethical clearance board.

Data Analysis
After receiving the data, data were merged and further data cleaning was done. The quantitative data were processed by using Excel (double data entry) for data validation. Data analysis was done using Epi Info 6 and SPSS to calculate proportion, Pearson 2, CI, OR, and z-test. A p value of less than .05 was considered as the minimum level of significance. The qualitative data like FGD, in-depth interview, and case study, content analysis was done to see the association.

Results
Despite the limitations of reporting bias, the findings highlight the complex and often contradictory nature of the relationships among factors at different levels, and the ways in which they influence womens risk of violence.

Abuse During Pregnancy and Outcome of Pregnancy

At a theoretical level, it is established that violence during pregnancy leads to bad obstetric outcome. Antenatal care is often neglected by the family members especially in a situation where a woman confronting violence for one or the other reasons within the family. To see if there is any impact of domestic violence during the pregnancy period an analysis was done by segregating the women who faced any form of abuses and those who did not face any form of abuses or domestic violence in the family during the last pregnancy only. It is important to note that the figures presented in Figure 1 are based on women experiencing violence during their last pregnancy and hence cannot be compared with the prevalence rate.

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120

% of Domestic Violence

100 80 60 40 20 0

Physical Violence Psychological Violence Sexual Violence

tra l W es t So ut N h or th Ea st th st Ea To t or al

en

Zones

Figure 1. Abuse during pregnancy by zone

Across the zone, women reported that about 63% (n = 1,715) women faced with psychological violence, followed with 26% (n = 720) physical violence, and 22% (n = 607) sexual violence during the period of their last pregnancy (see Figure 1). Zonal variation depicts the poorer situation of northern women facing more sexual violence (50%) in comparison with other zones. If seen through the distribution across the zones, western zone has recorded as very high percentage of physical violence as more than 50% women reported followed by southern zone (43%). Whereas, women reported of psychological violence during pregnancy was more recorded in central, northeast, and northern zones which were as high as more than or about 90%. In central zone, it is seen that quite a large number of women received violence during all the pregnancies and more women were subjected to psychological violence than physical and sexual violence. In northeast, 62% of women reported that they received domestic violence during pregnancy. Such violence has wide ranging health consequences for the pregnant women and puts her in double jeopardy, for herself, and also for her unborn child.

Impact of Domestic Violence on Pregnancy Outcome

On the whole, the affect of domestic violence can be seen on the pregnancy outcome also. The affect is however limited to preterm delivery, stillbirth,

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and miscarriage. Ten percent of the women who were the victims of domestic abuses during the last pregnancy had preterm live birth as against 5% among those who did not face any form of abuse. In northeast, adverse pregnancy outcome was not reported among the women experiencing domestic violence. Though the association was established between domestic abuse and reproductive outcome, the correlation or precise mechanism by which these outcomes occur was not clear and could not be supported by research as there was paucity of perspective studies in this aspect. The sexual practice during pregnancy seems to be the usual course of marital life as the pregnancy was considered to be normal phenomena. In fact men seem to be unaware of the consequences of sexual practices during pregnancy particularly in the third trimester of the pregnancy. During the discussion with the men it was reported that they forced their wives to have sex during the pregnancy and did not notice any adverse affect either on the pregnancy or delivery. Some of the men pointed out during the discussion that their wives were subjected to torture and verbal abuse quite often for one or the other reasons during the pregnancy period but the affect on the pregnancy was unnoticeable. According to them the incidence of miscarriage, abortion, and fetal deformity has no association with any form of domestic abuse. These are the fine examples of knowledge gap among men counterpart which may have serious implications particularly on the reproductive health of the women. Table 1 shows that prevalence of sexual violence during pregnancies among women in six zones. Though direct association between sexual violence and its impact on pregnancy outcome may not be possible, but across the zone data indicate that stillbirth and miscarriage together accounts a significant percent where women faced sexual violence. In central zone, about 23% women reported continuation of intercourse with usual occurrence as during normal time; however, a large percentage of women respondents reported decrease in frequency. In northeast, sexual violence was found to be very low (2%). However, an interesting finding in overall was that the number of women reporting sexual violence during pregnancy was increasing at every subsequent pregnancy.

Domestic Violence and Care During Pregnancy

At theoretical level, among women who are subjected to domestic violence, the access to and utilization of antenatal care is less. Table 2 describes the details of antenatal and other care during pregnancy and pressure of delivering male child who are exposed to any form of domestic violence.

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Table 1. Sexual Violence Versus Pregnancy Outcome by Zone

Pregnancy outcome PTLB Stillbirth Miscarriage Induced abortion Current pregnant Total

Zone

FTLB

North

Sexual violence

Nonsexual violence

East

Sexual violence

Nonsexual violence

Central

Sexual violence

Nonsexual violence

West

Sexual violence

Nonsexual violence

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South

Sexual violence

Nonsexual violence

Northeast

Sexual violence

Nonsexual violence

238 87.8 270 95.4 136 85.5 1152 84.3 92 94.8 451 96.4 146 85.9 288 86.2 19 52.8 83 90.2 17 100.0 69 98.6

29 10.7 9 3.2 9 5.7 100 7.3 4 4.1 13 2.8 15 8.8 37 11.1 2 5.6 7 7.6 1 1.4

1 0.4 1 0.6 10 0.7 1 0.2 1 0.6 1 0.3 10 27.8 1 1.1

2 0.7 3 1.1 5 3.1 18 1.3 1 1.0 2 0.4 3 1.8 5 1.5 4 11.1

1 0.1 2 1.2

1 0.4 1 0.4 8 5.0 85 6.2 1 0.2 3 1.8 3 0.9 1 2.8 1 1.1

271 100.0 283 100.0 159 100.0 1366 100.0 97 100.0 468 100.0 170 100.0 334 100.0 36 100.0 92 100.0 17 100.0 70 100.0

Note: FTLB = full-term life birth; PTLB = pre-term life birth.

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Central No Yes No Yes No Yes No Yes No West South Northeast Yes Total No 3 (60.0) 180 (54.2) 124 (72.5) 2 (40.0) 117 (35.2) 22 (12.9) 0 (0.0) 35 (10.5) 25 (14.6) 4 (80.0) 269 (81.0) 161 (94.2) 67 (73.6) 34 (94.4) 55 (60.4) 35 (38.5) 1 (1.1) 26 (72.2) 1 (2.8) 9 (25.0) 32 (37.2) 53 (61.6) 1 (1.2) 85 (98.8) 0 (0.0) 1374 (66.1) 1 (100) 624 (30.0) 0 (0.0) 82 (3.9) 1 (100.0) 1582 (76.1) 818 (64.0) 183 (14.3) 277 (21.7) 1103 (86.3) 42 (7.5) 0 (0.0) 79 (23.8) 17 (9.9) 49 (53.8) 16 (44.4) 8 (9.3) 0 (0.0) 504 (24.2) 189 (14.8) 5 (0.4) 332 (16.0) 171 (13.4) 91 (4.4) 36 (2.8) 86 (4.1) 1 (0.1) 2080 (100.0) 1278 (100.0)

Table 2. Care During Pregnancy and Domestic Violence by Zone

North

East

Yes

No

Yes

29 (96.7) 319 (65.1) 636 (61.4) 423 (75.5) 1 (3.3) 131 (26.7) 156 (15.1) 137 (24.5) 0 (0.0) 40 (8.2) 243 (23.5) 0 (0.0)

29 (96.7) 348 (71.0) 874 (84.4) 420 (75.0)

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Women facing any form of DV Adequate food and rest Same 365 (70.1) Decreased 151 (29.0) Increased 5 (1.0) Antenatal care/immunization 393 (75.4) Received antenatal care/ immunization Pressure of 204 (39.2) delivering male child Total 521 (25.0)

1 (3.3)

122 (24.9) 155 (15.0)

30 (2.3)

490 (23.6) 1035 (81.0) 560 (26.9)

Note: *Values for only those women who had reported that they had received antenatal care/immunization & Pressure of delivering male child, have been considered * Calculation has been done separately from the row-wise total for each variable

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Antenatal Care During Pregnancy

It is also well-known fact that among women who are subjected to domestic violence, the access to and utilization of antenatal care is less. Data indicate that antenatal care/immunization is much higher about 10% where the women were not facing domestic abuse (86%) while the antenatal care seems less where such incidence was found (76%). The difference is considered to be extremely statistically significant (z = 7.16, p = .0001). The difference is more visible in the northern and southern zones, where women were subjected to abuse and receive of antenatal care.

Food Intake and Rest During Pregnancy

The women were asked whether their food intake and rest were same as usual or decreased or increased during pregnancy. The data were segregated for the women those who are facing domestic violence and those who are not facing domestic violence. Women facing any type of violence data reflect a significant difference (z = 10.283, p = .0001) in having adequate food and rest to the pregnant women is concerned, infact their food intake and rest have been decreased compared with the women who were not facing violence. Where the women reported to have increased their food intake and rest, a similar trend is observed that the women not facing domestic violence, their food intake and rest has been increased much more compared with the women facing domestic violence and difference seems to be highly significant (z = 16.086, p = .0001). The trend is universal for all the six zones. In northeast, women who reported domestic violence during pregnancy did not get adequate food and rest during pregnancy.

Demand for Male Child and Pregnancy Outcome

Table 2 provide information on the demand for a male child and pregnancy outcome. Across the zones, demand for male child is much higher (24%) where the women were facing domestic abuse while the demand seems almost negligible where such incidence was not found which is statistically significant (z = 6.519, p = .0001). It is more pronounced in the southern zone (about 54%) irrespective of women facing domestic violence. This signifies the existing notion of male preference over female. In western zone, a woman during the discussion reported to have said that she was forced to abort the fetus which was detected to be the female. On this issue, women have strong views that women are subjected to abuse to any extent if they fail to deliver

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Table 3. Responsibility for Having Girl Child as Perceived by Men and Any One Form of Domestic Violence
Zone North Responsibility Self Wife Both God Others Total n (%) 31 (40.8) 11 (45.8) 26 (31.0) 137 (59.8) 2 (33.3) 207 (49.4) East n (%) 13 (40.6) 19 (95.0) 36 (75.0) 101 (57.4) 0 (0.0) 169 (61.2) Central n (%) 15 (25.9) 77 (84.6) 293 (39.6) 142 (40.7) 12 (17.9) 539 (41.3) West n (%) 6 (60.0) 10 (62.5) 44 (48.9) 31 (36.5) 10 (20.8) 101 (40.6) South n (%) 15 (40.5) 23 (74.2) 50 (51.5) 78 (37.0) 2 (33.3) 168 (44.0) Northeast n (%) 0 (0.0) 0 (0.0) 6 (6.7) 36 (20.3) 2 (18.2) 44 (15.8) Total n (%) 80 (6.5) 140 (11.4) 455 (37.1) 525 (42.8) 28 (2.3) 1,288 (100.0)

Note: Reported by men.

at least one son in their life time. They were of the opinion that family support and care to her is badly affected in the family if a female child is delivered and the discrimination is apparent between the male and female upbringing.

Responsibility for Having Girl Child as Perceived by Men

It was attempted to understand the perception of men about the prevalence of any one form of domestic violence of having girl child (see Table 3). Overall in all the six zones, if women were responsible for having girl child, any one form of domestic violence was more (11.4%) compared with the men (only 6.5%) responsible for it. In eastern zone, it was significant as much as 95% if the responsibility of having girl child lay with women. However, in northeast, the responsibility of having girl child lay with God (20.3%). The following two focus group discussions were conducted to get a collective response to understand the women and men perspective on issues of violence during pregnancy and its effects in the urban and rural setup.

Case 1
Location: State: Maharastra; District: Kolhapur; Village: Mangalvarpet Category: Urban; Group: Female Time: Evening 5 p.m. The participants say that sex during pregnancy occurs in cases where the husband is either illiterate or very young, or even if the wife is older than the

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husband; however, they did not explain the logic behind this statement. They are aware that forced sex during pregnancy can adversely affect the fetus, but no such cases have been reported so far. In their opinion, forced sex also occurs if a couple has no sons. The members perceive that men could demand sex from their wives even during pregnancy when they are drunk or are suspicious by nature. They reveal that in many cases the husbands even disown the newborn child alleging someone else to be the childs father. Participants reported that women are often taunted during pregnancy for various reasons; but only one of them perceives that there could be physical violence on the women during pregnancy. All of them say that they have come across several situations in other families where the wife is tormented because she has no sons, and is sent back to her mother place if she gives birth to a daughter. They recount a case where a woman was forced to go in for sex determination test and abort the fetus when it was found to be a female. There have also been instances in which, if the woman had no brothers, in-laws would take it for granted that she too would only bear daughters, blaming the expectant mother. They were of the opinion that women fear the wrath of their husbands and that they may be thrown out of the house, if they insist on keeping the female fetus. They also reported that illegal sex-determination test should be banned, and the corrupt practices of the doctors should be stopped. Sex during pregnancy occurs mostly when husband is illiterate, very young or if the wife is older, or if the couples have no sons. Participants think that forced sex during pregnancy could lead to physical deformities in the fetus.

Case 2: Focus Group Discussion: Male

Location: State: Gujarat; District: Navsari; Village: Bhata Category: Rural; Group: Male Time: Evening 6 p.m. Violence during pregnancy takes on two major forms, first of being taunted if the woman gives birth to a daughter and second, forcing sex while the woman is pregnant. In the later case, the participants admit that they were careful to see that she was not hurt and did not experience any pain. Forced sex also emerged as a point of discussion. They believed that normal sex is possible up to 6 months of pregnancy, but if the husband was in the drunken state, there was no way they could refuse and if they did, the husband would scream and create nuisance. Members of the group were aware that violence inflicted on the women when she was pregnant can lead to deformity or

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miscarriage. However, none of them have witnessed such a case around their societies. Violence during pregnancy takes the psychological form of pressure and taunting to give birth to a male child. Suggestions to overcome violence are education of women and awareness of womens rights. Media should play an appropriate role and assistance from local organizations.

Discussion
In this study, the analysis shed some light on the issues of reproductive health consequences that women suffer due to domestic violence. The study has revealed that the frequency of physical violence during pregnancy has an association with miscarriage, stillbirth, premature labor, late entry in to antenatal care/immunization including rest, and food intake of the pregnant women (Krug et al., 2002; Peedicayil et al., 2004). Pregnancy represents a period of increased vulnerability to domestic violence (Berenson, Stiglich, Wilkinson, & Anderson, 1991). Across the zone, data indicate that stillbirth and miscarriage together accounts a significant percent where women faced sexual violence. The study has revealed that the frequency of serious physical abuse during pregnancy to the women facing domestic violence is reportedly more and is associated with detrimental outcomes of pregnancy (Peedicayil et al., 2004; Jasinski, 2004). This in a way the argument can be developed that domestic violence during pregnancy has a bearing on maternal mortality which is reported to be high in this study particularly in the eastern and central zones of India (NFHS-3, International Institute for Population Sciences (IIPS) and ORC Macro, 2007). Similar observations were also reported from around the world that IPV is noted in 3% to 13% of pregnancies in many studies (Reardon et al., 2002; World Health Organisations, 2000). Though, the government is committed to allocating adequate resources to prevent maternal deaths and provide emergency obstetric care and special attention is being given to improving the health and well-being of women and children, domestic violence has been contributing to a large account goes unnoticed. Antenatal care is often neglected by the family members especially in a situation where a woman confronting violence for one or the other reasons within the family. Similar observations were also reported from around the world that antenatal care was much higher where the women were not facing domestic abuse while the antenatal care seems less where such incidence was found (Purwar et al., 1999). As far as adequate food and rest to the pregnant women was concerned, significant association was reported where women facing any form of violence compare to the women who were not facing violence (Kajsa et al., 2003). These factors not only affect the mothers health

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but can have a future affect on the newborn. The discussion which follows further elaborates on the findings related to the factors discussed on demand for male child and the responsibility of having a girl child. Inspite of various initiatives taken by the government in information, education, and communication (IEC) projects, people are still ignorant and God or women are held responsible for delivering a girl child. Despite our years of activism, legal system, police, and so on in the field of violence against women, it has not shown a positive development. There have been various prejudices that of male dominant society, and predominant culture and society as a whole. Research has shown that policy and legal reforms has little to contribute in changing the institutional culture and practice. Specifically, at the policy level, concerted efforts are needed to combat gender-based violence not only as a human rights issue but as a major risk factor for poor maternal and newborn health. In spite of Reproductive and Child Health (RCH) programs focusing on women and child health in India, needs integrated effort of various programs, state, local government, and civil society. Moreover, attitudinal alternation of men toward women would bring the real change. Further research, preferably utilizing longitudinal designs, is needed to find out the pathways, causal mechanisms linking violence with maternal and newborn outcomes, preterm labor, abortion rate, and the like. Domestic violence has emerged as one of the most significant health care threats for women and her unborn child. The effect of violence on health of the mothers requires appropriate interventions to avoid or minimize the effects of violence on the health of the mothers and the babies. In India, at the village level, Rural Health Mission (NRHM) is providing three antenatal checkups to the entire pregnant mother. To prevent the effect of domestic violence, all pregnant mothers should be treated as at risk, and routinely screened along with three antenatal care by Accredited Social Health Activist (ASHA) (National Rural Health Mission, 2005-2012) be institutionalized. The primary health care institutions in India should institutionalize the routine screening and treatment for violence related injuries and trauma and should render judicial and administrative support to the victims of the violence. This would enable to identify and develop database for public health intervention. An effort at every village toward forming a women action group or by strengthening the existing women self-help groups (SHGs) to facilitate the necessary help to the victims of domestic violence and enable with intragroup exchange of knowledge about their rights, treatment, and support. Appropriate mechanism should be installed for access to necessary help and cooperation from local government/panchayat and provision of rehabilitation. Provision

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of untied funds with local institution/panchayats should be made to provide immediate financial help to the victims of domestic violence. Acknowledgment
The authors sincerely acknowledge the support of Prof. N.K.Ganguly, Former DG, ICMR for his support and grant make to all the six participating centres. They also acknowledge the technical support provided by former Chief Social & Behavioural Research Unit, ICMR. The authors also acknowledge the contribution of Principal Investigators, Co-Principal investigators and field staff of the six participating centre, Taleem Research Foundation, Ahmedabad, Mahila Chetna Manch, Bhopal, Vulimiri Ramalingaswami Foundation, New Delhi, Regional Medical Research Centre, Dibrugarh, Regional Medical Research Centre, Bhubaneswar and National Institute of Mental Health and Neuro Sciences, Bangalore for generating the data for this multicentre study.

Declaration of Conflicting Interests

The authors declared that they had no conflicts of interest with respect to their authorship or the publication of this article.

Funding
The authors declared that they received no financial support for their research and/or authorship of this article.

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Bios
Meerambika Mahapatro, PhD, is working as Reader at National Institute of Health & Family Welfare, Baba Ganganath Marg Munirka, New Delhi, India 110067. She is also affiliated to Indian Council of Medical Research, Ansari Nagar, New Delhi110024. R.N.Gupta, PhD, Former Chief & Scientist F, Social & Behavioural Research Unit, Indian Council of Medical Research, New Delhi. Vinay Gupta, M.Phil, Bio-Statistician, Health Related Information Dissemination amongst Youth (HRIDAY), New Delhi. A.S.Kundu, PhD, Scientist E Indian Council of Medical Research, New Delhi.

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