Reproductive Health Outcomes

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Results Fifty-four percent of men reported not abusing their wives, while 17Y" re- ported physically but not sexually abusing their wives, 22Y" reporled sexual ...
Reprinted from JAMA @ The Journal of the Ameican Medical Association Novembet 24, 1999 Volume

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282

Copyright 1999, American Medical Association

LETTER FROM

UTIAR PRADESH

Sexual Behaviors and Reproductive Health Outcomes Associations With Wife Abuse in India Sandra L. Martin, PhD

Context Wife abuse has been associated with a variety of health

Brian Kilgallen, MSc

tions between abuse and reproductive health in lndia are not well known.

Amy Ong Tsui, PhD

Objective To examine relationships between men's reports of wife

Kuhu Maitra, MD Kaushalendra Kumar Singh, PhD Lawrence L. Kupper, PhD IOLENCE AGAINST WOMEN, INcluding physical and sexual vioIence, is increasingly being rec-

ognized as an important global health problem. Although many women have suffered violence at the hands ofstrangers, more commonly the violence perpetrators are the women's intimate partners (husbands or boyfriends). Studies

in developed and developing countries have found thatnumerous women have been victims of abusive behavior,r and that approximately 5o/o of the healthy years of life lost to women o[ reproductive age in developing countries is due to violence.2 Given that there has been some documentation of wife abuse in India,3"la and that young women are at high risk for abuse, it is important to examine potential associations between abuse and

reproductive health issues of women and their partners.15-17 Although traditional Indian value systems condemn

sexual relationships outside mar-

abuse and re-

productive health issues in northern lndia,

Design Structured face-to-face interviews were conducted

as part of the mde reproductive health supplement of the PERFORM System of lndicators Survey, a systematic multistage survey conducted in 1995-1995.

Setting The northern state of Uttar

Pradesh, one of the least developed states in

lndia.

Participants A total of 6532 married men aged 15 to 65 years who lived with their wives and completed all survey questions for the study variables reported here. Main Measures Physically and sexually abusive behaviors toward wives, sexual activities outside marriage, sexually transmitted disease (STD) symptoms, contraception use, unplanned pregnancies, and sociodemographic characteristics.

Results Fifty-four percent of men reported not

abusing their wives, while 17Y" reported physically but not sexually abusing their wives, 22Y" reporled sexual abuse without physical force, and 77" reported sexual abuse with physical force. Abuse was more comriron among men who had extramarital sex (for sexual abuse using force: odds

ratio [ORj, 6.22;95% confidence interval lClJ,3.98-9.72). Similarly, men who had

STD symptoms were more likely to abuse their wives (with current symptoms: OR, 2.431 95% Cl, 1.73-3.42). Unplanned pregnancies were significantly more common among wives of abusive men, especially sexually abusive men who used force (OR,

2.62t 95% Cl, 1.91-3.50). abuse appears to be fairly common in northern lndia. Our findings that abusive men were more likely to engage in extramarital sex and have STD symptoms suggest that these men may be acquiring STDs from their extramarital relationships, thereby placing their wives at risk for STD acquisition, sometimes via sexual

Conclusions Wife

abuse. These abusive sexual behaviors also may result in an elevated rate of unplanned pregnancies. I AMA.

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recentlarge-scale survey of men in India found that the majority of men (about

there are suggestions that these

two thirds) felt that wives should fol-

norms are changing, resulting in

low the instructions of their hus-

increased premarital and extramarital sex.2t-22 Cultural attitudes in India also

bands; however, only a minority of men

embody the notion that wives should be respectful to their husbands and should try to obey their commands; however, the use of physical force by husbands as a means of controlling their wives is not as widely sanctioned in the culture. For example, findings from a

cally beating one's wife was justified if she disobeyed her husband.23 It is

riage,18-20

concerns. Associa-

(about one quarter) felt that physi-

hypothesized here that men who engage in this less socially acceptable behavior of wife abuse may be more likely than nonabusive men also to violate tra-

ditional social norms by being sexu-

ally active with persons other than their wives. Furthermore, if abusive men are more likely to be sexually active with AuthorAffiliations: Department of Maternal and Child Health (Drs Martin, Tsui, and Maitra), Department of Biostatistics (Dr Kupper and Mr Kilgallen), and Carolina Population Center (Dr Tsui), University of North Carolina, Chapel Hill; and Depadment of Statistics, Faculty of Science, Banaras Hindu University, Varanasi, lndia (Dr Singh). Corresponding Author and Reprints: Sandra L. Mar-

tin, PhD, Department of Maternal and Child Health, CB 74OO, University of North Carolina, Chapel Hill, NC 27599-7 4OO (e-mail: [email protected]). Letter From Section Editor: Annette Flanagin, RN, MA, Managing Senior Editor.

JAMA, November

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LETTER FROM UTTAR PRADESH

multiple partners, they also may be more likely to acquire sexually transmitted diseases (STDs). Although there have been suggestions that women in abusive relationships may be less likely than nonabused women to use contraception because they flear violent reactions from their husbands (he may feel that decreasing his wife's risk of pregnancy will increase her likelihood of having sex with other men),2a I Indian

study found a positive association between abuse and contraception.25 Since the relationship between abuse and contraception has seldom been investigated and remains unclear, this

study also examines associations between wife abuse and contraceptive use and unwanted pregnancy. Thus, this article extends past research concerning wife abuse in India by examining

abuse related to several important domains of reproductive health, including men's experiences of sexual activity-outside marriage, men's STD symptoms, the couple's use of contraception, and unplanned pregnancies.

A'IETHODS Study Sefting and Sample This investigation is part of the male re-

productive health supplement of the PERFORM Sysrem of Indicators Survey conducted during 1995-1996.26 The study setting was the northern Indian state of Uttar Pradesh, one of the least developed Indian srates,27 although there is considerable variability in the sociodemographic characteristics of the people living in the stare's 5 regions. The

sampling frame for this systematic multistage survey (described in detail elsewhere)28 consisted of married men, aged

l5 through 65 years, from approximately 400 villages and towns in 5 districts in the 5 regions of Uttar Pradesh. A total of 8296 eligible men were enumerated in the household listing of the study districts implemented at the initiation of the PERFORM Survey. A total of 6902 of these men (83olo) agreed to and completed the full male interview. Of the 6902 men interviewed, 6632 (960/.) met rhe conditions of living with their wives and having com1968

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plete information on all of the study variables reported here.

Assessment A structured face-to-face interview was

administered to study participants by trained male interviewers from Uttar Pradesh. Care was taken to establish rapport with respondents prior to interview administration, and interviewers stressed that honest answers were needed to sensitive questions to gain

insight into the health of rhe state,s people. Participants were assured of the confidentiality of their responses. Interviews took place in a private area within the men's homes. If another person entered the interview area, interviewers either stopped the interview un-

til

the person left, moved to a privare area and then continued, or left the residence and returned at another time when privacy was available. The interview contained questions concerning health-related factors, including the men's physically and sexu-

ally abusive behaviors toward their wives. Wife abuse was assessed by ask-

ing men 1 question concerning physical abuse (specifically, "Have you ever hit, slapped, kicked, or otherwise physically hurt your wife?") and 2 questions concerning sexual abuse (specifically, "Have you ever had sex with your wife even if she was not willing?" and "Have you ever physically forced your wife to have sex?"). For analysis purposes, each male participant was classified into 1 of 4 groups on the basis of the men's responses to the 3 abuse questions: (1) the no abuse group, defined as men who did not report perpetration ofphysical abuse, nonconsensual sex, or physically forced sex; (2) thephysical abuse only group, defined as men who reported perpetrating physi-

cal abuse) ; an d (4) the sexual abuse with si c al f o r c e gr oup, defined as men who

phy

reported physically forcing their wives

to have nonconsensual sex (note that all

ofthis group reported having nonconsensualsexand theymayormaynothave also reported physical abuse).

The interview also included questions concerning 3 groups ofvariables regarding the men's reproductive health and behavior. The first of these variable groups focused on the men's sexual

behavior outside marriage, specifically, whether the men had engaged in premarital sex (intercourse before mar-

riage) and whether the men had engaged in extramarital sex (intercourse with someone other than their wife af-

ter marriage). The second group of reproductive health variables concerned the men's STD sl.rnptom status and were adapted from the Philippines Safe Motherhood survey and others.2e Men were asked about having each of 7 STD indicators during 3 points in their lives (before marriage, any time after mar-

riage, and at the time of the interview). These indicators were based on clinically derived recommendations for sl.ndromic diagnosis and treatment of STDs from UNAIDS and the World Health Organization3o and included

having any of the following: a discharge from the penis, genital or anal sores, diflficulty urinating, painful uri-

nation, frequent urination, swelling in the testes or groin area, and a positive slphilis test. The sensitivity and specificity of this approach will vary depending on the tlpe of STD and whether the STD is currently sympromaric; however, studies conducted in developing

countries suggest that this syndromatic approach may be superior to reliance on clinical diagnosis alone.3l For

cal abuse, but who did not report perpetration ofnonconsensual sex or physically forced se x; (3) the s evral abus e w ithoutphysicalforce group, defined as men who reported having nonconsensual sex

analysis purposes, men who reported that they had 1 or more of these indicators were classified as being symp-

with theirwives, butwho reported that

health variables concerned the cou-

they did not physically force their wives to have sex (note that men in this group also may or may not have reported physi-

tomatic for an STD.

The third group of reproductive ple's contraceptive behaviors and associated outcomes. Specifically, men were asked whether the couple used

LETTER FROM UTTAR PRADESH

contraception during the time of the study and whether the couple ever had an unplanned pregnancy.

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The survey also gathered sociodemographic information, including the

men's geographic district of residence, ruraVurban status, age (classi-

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fiedas "younger" if themenwere (3I years and "older" if they were 23I years), Ievel of education (classified as "lower" if the men had