Prevalence of Domestic Violence among Infertile Women attending Subfertility Clinic of a Tertiary Hospital

ABSTRACT Introduction: Millions of couples suffered from Infertility worldwide. Infertility can cause intense emotional pain in women resulting in stress, anxiety and depression. Domestic violence in infertile women can further results in poor health status and lowers the quality of life. The objective of this study is to find out the prevalence of domestic violence among infertile women attending subfertility clinic of tertiary hospital. Methods: This descriptive cross-sectional study was conducted among infertile women in a tertiary hospital from July to August 2018 after taking ethical approval. Convenient sampling was used. Face to face interview was conducted using a structured interview schedule. Data analysis was done in the Statistical Package for Social Sciences. Descriptive statistics (frequency, percentage) were used to analyze the data. Point estimate at 95% CI was calculated along with frequency and proportion for binary data. Results: Domestic violence was found among 62 (55.35%) women at 95% Confidence Interval (46.15-64.55). The emotional violence accounted for 57 (50.89%), physical violence for 19 (16.96%) and sexual violence for 18 (16.07%). The prevalence of domestic violence was more 22 (61.11%) in women with secondary infertility than in women with primary infertility 40 (52.63%). The main perpetrators of domestic violence were family members 28 (45.16%). Conclusions: The study concluded that women experiencing infertility are exposed to various forms of domestic violence, emotional one being most common. Routine screening for domestic violence in infertility clinics is necessary to give affected women an opportunity to access appropriate health care and support services.


INTRODUCITON
Childbearing is an immense pleasure for every woman. Globally there are about 48.5 million infertile couples and 14.4 million of them live in South Asia. 1 In Nepal, although a child holds the greatest importance to the couples and families, most of the women are facing the silent tragedy of infertility. 2 The consequences of infertility in developing countries like Nepal range from poor marital adjustment, social isolation, psychological effects, and violence. 3 Violence, stress, anxiety, and depression occurs in a vicious cycle in infertile women that lowers the quality of life and success of treatment. [4][5][6] Many of them end up committing suicide and self-injurious behavior. 7 As JNMA I VOL 58 I ISSUE 226 I JUNE 2020 violence is a major health and human rights concern and scarcity of studies in related areas has motivated for the conduction of the study.
The present study aims to find out the prevalence of domestic violence among infertile women in a tertiary hospital.

METHODS
A descriptive cross-sectional study was conducted in a tertiary hospital over a period of one month from July to August 2018. Ethical clearance was taken from the Institutional Review Board of National Academy of Medical Sciences and Institutional Review committee of PMWH. Data were collected from 112 women attending the subfertility clinic of PMWH after obtaining written consent.
The sample size of the study was estimated for a finite population using a confidence interval of 95%. The sample size was calculated using a standard formula. Non-response rate= 5% Therefore the final sample size for the study was 112.
Convenient sampling technique was used in this study. Every day all the women visiting the subfertility clinic for consultation regarding infertility management were identified from the distinct subfertility OPD card as the women with other gynecological problems also visit the subfertility clinic of PMWH. Those who were willing to participate were included in the study and were invited to a private room after their consultation with the doctor. Written informed consent was obtained. Women attending Extended Hospital Service (EHS) were not included in the study.
Face to face interview was conducted with women in the absence of their spouse using a standard tool used in Nepal demographic and health survey (NDHS),2016 to assess the prevalence of domestic violence. 9 Threaten of divorce is added to the emotional violence as literature has shown a high prevalence of it. 10,11 Data were coded for entry and analysis into Statistical Package for Social Sciences (SPSS) version 16. Descriptive statistics (frequency and percentage) were used to describe the quantitative study variables.

RESULTS
The results showed that among 112 women, 62 (55.35%) experienced some types of domestic violence in the last 12 months. The prevalence of domestic violence in women with primary infertility was 40 (52.63%) whereas those in secondary infertility were 22 (61.11%) ( Table 1). were also more prevalent in women with secondary infertility (Table 2).  The majority of the women 67 (59.82%) belonged to a single family (Table 4). The fertility specific characteristics of women are shown. The mean age at marriage was 22±4 years. The duration of marriage was five years and less in most 73 (65.18%) of the women. In regards to the duration of infertility, the majority 57 (50.89%) of the woman were of categories more than two years (Table  5).

DISCUSSION
In our study, 62 (55.35%) of women experienced some types of domestic violence in the last 12 months. The findings are also supported by another study conducted in India. 12 However, the prevalence was found much higher in the Iranian setting. 13,14 These differences may be due to cultural diversities in the study population as well as a different data collection tool.
In our study, violence was found higher 22 (61.11%) in women with secondary infertility in comparison to women with primary infertility 40 (52.63%). These figures are comparable to the figures obtained in Pakistan where violence on the base of gender has a similar prevalence revealing that women with no live children were more likely to be the victims of violence compared to those who had a live child. 10 In contrary to this study, a study done in Nigeria revealed that the women who have two or more children were more likely to experience spousal violence compared with childless women. 15 In the present study, emotional violence was most 57 (50.89%) common form of violence. In a study verbal abuse was the most common type of violence followed by intimidation for divorce. The percentage of women experiencing physical violence was 19 (16.96%) in our study. This is similar to figures recorded in studies performed in India. 12 Unlike our findings, the study conducted in another part of India showed a higher prevalence of physical violence. 8 The current study further illustrated the prevalence of sexual violence as 18 (16.07%) in the form of forceful JNMA I VOL 58 I ISSUE 226 I JUNE 2020 sexual intercourse or sexual positions, the highest proportion being the use of physical force to have sexual intercourse. Sexual violence was much higher in a study in Iranian and Nigerian setting. 16,17 Women hesitation to open up about sexual activities may be the reason for this contradiction.
In regards to perpetrators of domestic violence, the majority of them were family members 28 (45.16%). In a qualitative study, most of the women expressed that they are tortured by their in-laws verbally. 11 In contrast to the study, a study done in Iran showed husband as perpetrators in all cases. 18 This study findings are not representative of the general population as the study was conducted in a selective tertiary hospital setting. The study does not address the situation among women with male factor infertility. Domestic violence especially the physical and sexual ones may not have been expressed due to cultural or social issues like shame and embarrassment.

CONCLUSIONS
The present study concluded that women experiencing infertility are subjected to various forms of domestic violence. Emotional violence was the most common type of violence whereas Physical and Sexual violence was nearly equally prevalent among infertile women.
Violence as being an issue of human right concern and overall quality of life of women, it is necessary to screen for violence in infertile women to identify those affected and to give these women an opportunity to access appropriate health care and support services.

ACKNOWLEDGMENTS
Our sincere hearty thanks and acknowledgment to all women who participated in this study to make this study possible.