Do Battered Mothers Have More Fetal and Infant Deaths? Evidence ...

Do Battered Mothers Have More Fetal and Infant Deaths?Evidence from IndiaNan E. JohnsonDepartment of SociologyMichigan State UniversityEast Lansing, MI 48824-1111TTY: 517/353-5974FAX: 517/432-2856Email: johnsonn@msu.eduManisha SenguptaPopulation Division, U.S. Census BureauWashington, D.C.Tel: 301/763-1373Email: manisha.sengupta@census.govPopulation Studies Center Research Report 08-634March 2008Acknowledgments: Earlier drafts of this paper were presented at the annualmeetings of the Population Association of America, Los Angeles, April 1, 2006, and ata brownbag seminar of the Population Studies Center at the University of Michigan,Ann Arbor, on October 9, 2006. We thank Saifuddin Ahmed and Lori Post for helpfulcomments on earlier drafts.

More Infant and Fetal Deaths among Battered Women? Evidence from India 2ABSTRACTThis study uses Poisson regressions to analyze data from the 1998-99 National Family HealthSurvey of India. The two dependent variables are the incidence rates of involuntary fetal deaths andinfant deaths (per total number of children ever born per mother). The independent variable iswhether the mother has ever been “beaten or physically mistreated” by a husband or formerhusband since she was age 15. We find that mothers who report any corporal punishment inflictedby their husbands or former husbands also report a higher incidence rate of unintentional fetaldeaths than mothers who do not report conjugal battery. However, conjugal physical assault onmothers is not associated with a higher incidence rate of mortality among their infants. Theimplications for future research on domestic violence and for public health policy in India arediscussed.

More Infant and Fetal Deaths among Battered Women? Evidence from India 3INTRODUCTIONConjugal assault happens often in lesser developed countries (LDCs) where women havelow status. For examples, in 48 population-based surveys from around the world, 10 to 69 percentof women report being physically assaulted by an intimate male partner at some point in their lives;and from 4 to 20 percent of women in the LDCs report being beaten while pregnant (World HealthOrganization (WHO), 2004). In the United States (U.S.), the percentage of women who report beingseriously, physically assaulted by their spouses/partners (such as by being kicked, bitten, socked, orthreatened with a deadly weapon) is 38% higher for pregnant women (16.7%) than for non-pregnantwomen (12.1%) (Gelles 1988). In fact, men who physically assault their wives/partners may changethe nature of the attack (for example, by striking the abdomen rather than the face) to exploitwomen’s special vulnerability when pregnant (Gelles 1988: 845). This possibility raises thequestion: If mothers are battered, do they have more frequent fetal and infant deaths?India offers a worse - case scenario than other LDCs. At least half of battered Indian wivessay they have been beaten when pregnant (International Center for Research on Women, 2003). Inthis situation, the unborn fetus can suffer fetal distress or stillbirth, premature delivery, low birthweight, and/or death in infancy or early childhood (Asling-Monemi et al. 2003; Butchart andVillaveces 2003; WHO, 2004). In addition, wives of abusive husbands are probably at greater riskof contracting sexually transmitted infections (STIs), which can compromise fetal health, becausethese men are more prone to engage in such other risky behaviors as alcohol abuse, promiscuity,and polygamy (Kishor and Johnson 2006). Also, women who suffer battery by their husbands tendto lack the domestic authority to seek prenatal care for medical problems during pregnancy. For allthese reasons, we might expect that battered wives experience higher rates of involuntarymiscarriage, stillbirth, and infant mortality than wives with no experience of conjugal physicalviolence.Studies on the consequences of physical battery for women’s reproductive health have threetypical limitations. First, in the U.S., qualitative and quantitative sources of data on intimate -partner violence have resulted in two different literatures with different conclusions about itsfrequency and its gender asymmetry. Qualitative studies on women who stay at shelters forhomeless people, who are patients at hospital emergency rooms, or who file for divorce show: 1) ahigh frequency of man-on-woman assaults (an average of about 65 assaults per battered woman in ayear; see Johnson 1995: 287); 2) a pattern of escalation in this violence over time; and 3) a tendencyfor women not to strike back unless as a last resort. In contrast, quantitative studies on couplesresponding to the National (U.S.) Family Violence Surveys show: 1) a much lower frequency ofintimate-partner violence (assaulted women reported an average of six annual assaults in the 1985National Family Violence Survey; see Johnson 1995: 286); 2) a higher degree of gender balance in

More Infant and Fetal Deaths among Battered Women? Evidence from India 4who initiates the fight; and 3) a lower tendency for it to escalate into a risk for serious bodily harm.One explanation for these different findings is that battered women who participate in random -sample surveys are more likely than those in the qualitative studies to be still living with theirbatterer and thus more reluctant to report the batteries lest their men find it out. If true, theunderreporting might prevent researchers from observing an association between physical assault onwomen and their experience with fetal and infant deaths in U.S. sample surveys. Both U.S. andIndian wives will likely underreport intimate-partner violence to survey researchers. But the pooreraccess to prenatal and postnatal care faced by most Indian wives might unmask any relationshipbetween conjugal assault and fetal/infant death.Second, the few studies on this topic in LDCs usually look only at the health consequencesof mother-battering during her pregnancy and ignore what happens to her child after its birth. Anotable exception is Kishor and Johnson’s (2006) analysis of women ages 15-49 in theDemographic and Health Surveys in Cambodia, Haiti, and the Dominican Republic. They foundthat women with a high domestic-assault score (17% in Cambodia, 22% in the Dominican Republic,and 29% in Haiti) had significantly higher odds of reporting they had ever had a non-live birth, anSTI or its symptoms in the past year, or, with a single exception (Haiti), an unwanted birth withinthe past five years. In addition, among women who had ever experienced domestic violence, thosefrom households with the lowest quintile of wealth were not more likely than those from wealthierhouseholds to suffer these three negative health consequences. Thus, it seems that domesticviolence itself, and not the poverty with which it is frequently associated, plays a causal role incompromising women’s reproductive health.Third, the studies of the effects of domestic violence upon women’s reproductive-health areoften based on a rural or an urban area of a single state (for examples, see: Koenig et al. 2003; Rao1997). A geographically broader study was offered by Jejeebhoy (1998), who analyzed acommunity-based survey of women ages 15-39 who lived in the State of Uttar Pradesh in northernIndia or the State of Tamil Nadu in the southern India. She found that among women who had everhad at least one birth, the experience of conjugal battery raised the odds of at least one fetal death orinfant death, regardless of religion or region. However, these results cannot be generalized to All-India.RESEARCH QUESTIONSTo our knowledge, the present study is the first to use national-level data from India toexamine the relationship between conjugal assault on wives and their reproductive health. The tworesearch questions are:

More Infant and Fetal Deaths among Battered Women? Evidence from India 5Q1: Do Indian mothers have a larger number of involuntary fetal deaths (spontaneous abortions orstillbirths) if they report a history of physical assault by their husbands?Q2: Do Indian mothers have a larger number of live births that die in infancy if they report a historyof physical assault by their husbands?METHODSDataThe data set is the 1998-1999 National Family Health Survey of India (NFHS II). At thiswriting, it is the most recently released national survey regarding maternal and child health in India.It is a stratified random sample of households from all states and union territories. All ever-marriedwomen ages 13-49 from a sampled household were interviewed. We limit our focus to those at ages15-49, since the question about domestic battery refers only to physical assaults since age 15.Two Dependent VariablesThe first dependent variable is the ratio of the Study Woman’s total number of lifetimepregnancies that ended in an involuntary fetal death (i.e., a spontaneous abortion or a stillbirth) toher total number of live births. The birth-history questions that identified stillbirths, spontaneousabortions, or deliberate abortions were asked only of women who had had a birth since 1995(unweighted N = 80,862 Study Mothers; see Table 1). In enumerating fetal deaths per woman, weexclude deliberate abortions, since in India these are quite often performed to eliminate femalefetuses. Of all Study Mothers, 16.98% (=13,734; data not in table) reported at least one involuntaryfetal death during a pregnancy.The second dependent variable is the ratio of the number of infant deaths to a StudyMother’s total number of live births. We deleted 11,978 mothers who had given birth in the twelvemonths preceding the survey, since any such infants still living would not have been exposed to thefull 12 months in which to suffer infant mortality (or not) prior to the first birthday. Of theremaining 68,887 Study Mothers who contributed observations on the second dependent variable,20.77% had witnessed at least one death to their infants (data not in Table 1).Independent VariableThe NFHS II questionnaire asked whether a respondent had been beaten or physicallymistreated since age 15. If the respondent replied affirmatively, she was asked to identify theperpetrators from a list that included the husband or a former spouse. The independent variable wascoded: "1," if a woman said she had ever experienced conjugal physical violence; “0” otherwise.

More Infant and Fetal Deaths among Battered Women? Evidence from India 6Table 1. Characteristics of Mothers Ages 15-49 to Study Fetal or Infant Deaths, ByExperience of Conjugal Physical Violence: NFHS II.Mothers Ages 15-49 to Study:Involuntary Fetal Deaths Infant DeathsNo Violence Violence No. Violence Violence.% literate 44.45 26.83 44.28 27.03% with illiterate husbands 28.53 42.36 28.56 42.34% husbands with some primarySchooling 38.30 40.84 38.42 41.08% husbands with secondarySchooling or more 33.18 16.80 33.02 16.59% Muslim 12.53 12.87 12.01 12.25% rural 71.98 80.09 71.05 79.66% South 33.46 38.76 34.36 40.34Mean age at interview (yrs.) 32.06 31.98 33.50 33.00Mean Asset Ownership Index 2.27 1.65 2.32 1.69Mean Age at Marriage 16.93 15.97 14.89 15.96Mean Age at 1 st Birth 19.39 18.29 18.89 18.04Mean No. Children Ever Born 1.72 1.85 1.75 1.86Unweighted N of Study Mothers 67,065 13,797 56,894 11,993Weighted N of Study Mothers 335,325 68,895 284,470 59,965 .Note: The percentages and means in this table have been weighted to reflect the complex sampling design..Of the 80,862 Study Mothers in the analysis of fetal death (first two columns of Table 1),17.06% reported having been physically hurt or mistreated by a spouse or former spouse since age15. This prevalence rate is almost identical to that reported for Cambodia by Kishor and Johnson(2006). If a Study Mother had had a pregnancy end in an involuntary fetal death, she was morelikely than not to report conjugal physical violence (21.83% v. 16.09%; data not in Table 1). Thisrelationship is consistent with an affirmative answer to Question 1.Of the 68,887 Study Mothers used in the analysis of infant mortality (last two columns ofTable 1), 9.49% reported a history of conjugal violence. This is lower than the prevalence rate of17.06% reported by Study Mothers in our analysis of involuntary fetal deaths, and both prevalencerates are likely to be underreported. However, if fetal death is a more common result than infantdeath from episodes of conjugal attack on the mother, it may be less subject to selectiveunderreporting. In any case, conjugal violence was reportedly more prevalent among Study Motherswho had had one or more infant deaths than among Study Mothers with no infant deaths (22.04% v.6.20%; data not shown in Table 1). This bivariate relationship is consistent with an affirmativeanswer to Question 2.

More Infant and Fetal Deaths among Battered Women? Evidence from India 7Control VariablesThe published literature has identified several factors that appear to be associated both withwomen’s autonomy from patriarchal control (thus, likely to represent greater safety from conjugalassault) and with maternal and child health. For example, citing the case of Kerala State in India,Caldwell (1986) identified the importance of women’s literacy for child survival, even inimpoverished ecological settings. We measured the wife’s education as a dichotomy (1 = literate; 0= illiterate). In both populations of Study Mothers (columns 1 and 2 for fetal deaths and columns 3and 4 for infant deaths on Table 1), the percent literate was higher for those reporting no conjugalviolence than for those reporting any (about 44% vs. about 27%).For balance, the husband’s education was also controlled. It was trichotomized as: illiterate(no schooling); some primary schooling; or secondary schooling or higher. Only the Study Motherswhose husbands had reached the secondary level of school or higher were less likely to reportconjugal physical violence (Row 4, Table 1).At the household level, we measured socioeconomic status with an Asset Ownership Index,a ratio scale (0-6) summing the number of luxury items owned by the household: radio, television,refrigerator, bicycle, motorcycle, and car. For both populations of Study Mothers, the averagenumber of luxury items was greater for mothers reporting that no conjugal physical violence (Row9, Table 1).Koenig et al. (2003) reported that 42% of the women in their study in rural Bangladeshreported domestic physical violence, and that such reports were more common if the women wereMuslim. Thus we controlled residence (1=rural; 0 = urban) and religion (1 = Muslim; 0 = other). Inaddition, we controlled the Indian region of residence (1=South; 0 = North), because previoustheoretical work establishes that South Indian women are more autonomous in ways that reduce therisk of infant mortality (Dyson and Moore 1983).Place in the life course matters. In South Asia, a younger age at marriage or first birth istypically associated with a deeper integration into the patriarchal family, in which young wives aresubordinated to husbands and parents-in-law and may face a greater risk of physical violence fromthem. Mothers-in-law and grandmothers in India are more likely than other women to exercise theright to go to market without permission and to set aside money for their own discretionary usage(see Sengupta and Johnson 2006). Therefore, we control age at marriage, age at first birth, and ageat interview, all measured in single years.

More Infant and Fetal Deaths among Battered Women? Evidence from India 8Statistical ProceduresA woman’s total number of involuntary fetal deaths (the first dependent variable) and infantdeaths (the second dependent variable) did not follow a random normal distribution. Therefore, akey assumption of Ordinary Least Squares (OLS) regression was not met. For this reason, we usedPoisson regressions of the two dependent variables upon the test and control variables.As a special type of nonlinear regression, the Poisson regression (unlike the OLS regression)respects the condition that the measures of the dependent variable are non-negative, discretenumbers. The dependent variable in the Poisson regression may be viewed as the number of eventsobserved from a rate of occurrence, conditional on covariates. In the present study, the observedfrequency of the event of interest (involuntary fetal death or infant death) is the total number of suchinstances per the total number of children ever born to the respondent. The latter variable is treatedas an offset in the Poisson regressions below. For a comprehensive discussion of Poisson regressiontheory, see Cameron and Trivedi (1998).The Poisson regressions were calculated with the “svypoisson” procedure in the STATAVersion 8 software package. We used the “svyset” procedure to weight the data in all tablespresented and to correct the standard errors for the complex sampling design.RESULTSQ1: Do Indian mothers have a larger number of involuntary fetal deaths (spontaneous abortions orstillbirths) if they report a history of physical assault by their husbands?Study Mothers who have been physically assaulted by their husbands have an incidence rateof involuntary fetal deaths (per total number of children ever born) that is 1.22 times as large as forStudy Mothers with no history of conjugal battery (p

More Infant and Fetal Deaths among Battered Women? Evidence from India 9Table 2. Poisson Regression of Involuntary Fetal Death Rate Upon Mother’sExperience of Conjugal Assault, Plus Control Variables: NFHS IIIncidence Rate Ratio Standard Errore ß of ß t..Conjugal Assault (0=n;1=y) 1.22** .09 2.66Age at interview (yrs.) .80*** .01 -24.51Age at 1 st Birth (yrs.) 1.40*** .03 16.73Age at Marriage (yrs.) .97 .03 -1.30South (0=n;1=y) 1.86*** .19 6.09Muslim(0=n;1=y) .32*** .06 -5.67Asset Ownership Index 1.24*** .04 7.61Mother literate (0=n;1=y) 1.30* .14 2.44Husband’s education ref.: NoneHusband with some primarySchool (0=n;1=y) 1.20* .09 2.52Husband with secondarySchool or more (0=n;1=y) .96 .13 -.27Rural (0=n;1=y) 1.05 .10 .55Total no. Children Ever Born (offset)F(11,322) = 725.59*** .Note: The data in this table have been weighted to reflect the complex sampling design. UnweightedN = 80,862; weighted N = 404,310.* p < .05; ** p < .01; *** p < .001.Q2: Do Indian mothers have a larger number of live births that die in infancy if they report ahistory of physical assault by their husbands?Ceteris paribus, women with any history of conjugal physical assault produce live birthswith an incidence rate of infant mortality that is only 1.02 times as large as for women reporting nohistory of conjugal violence (p > .05, Table 3). In other words, the answer to Question 2 is no.Is it possible that husbands who inflict physical injuries on their pregnant wives and causespontaneous abortions (a possibility raised by our affirmative answer to Q1) might also commitinfanticide on the newborns before they reach the first birthday (the newborns becoming unreportedcases of infant mortality)? Female infants would be at special risk, since the preference for sons iswidespread in India (see Haub and Sharma 2006: 7-8). An indirect method of detecting femaleinfanticide would be to search for a larger infant – girl death rate attributable to “accidents” or“injuries.” Unfortunately, the cause of infant deaths was not asked in the questionnaire for the 1998-99 NFHS. This question must be left to future studies.

More Infant and Fetal Deaths among Battered Women? Evidence from India 10Table 3. Poisson Regression of Infant Death Rate Upon Mother’s Experienceof Conjugal Assault, Plus Control Variables: NFHS IIIncidence Rate Ratio Standard Errore ß of ß t..Conjugal Assault (0=n;1=y) 1.02 .09 0.18Age at interview (yrs.) .83*** .01 -23.65Age at 1 st Birth (yrs.) 1.25*** .04 7.71Age at Marriage (yrs.) .95 .04 -1.35South (0=n;1=y) 1.74*** .19 5.10Muslim(0=n;1=y) .24*** .05 -7.46Asset Ownership Index 1.18*** .04 4.62Mother literate (0=n;1=y) .88 .12 -.93Husband’s education ref.: NoneHusband with some primarySchool (0=n;1=y) 1.24** .10 2.65Husband with secondarySchool or more (0=n;1=y) .87 .12 -1.01Rural (0=n;1=y) 1.10 .12 .88Total No. Children Ever Born (offset)F(11,322) = 260.31*** .Note: The data in this table have been weighted to reflect the complex sampling design.Unweighted N = 68,887; weighted N = 344,435.* p < .05; ** p < .01; *** p < .001.DISCUSSIONFrom the National Family Health Survey of India in 1998-99, we find that mothers whoreport any corporal punishment inflicted by their husbands or former husbands also report a higherincidence rate of unintentional fetal deaths (per total number of children ever born) than motherswho do not report conjugal battery. Likewise, Jejeebhoy’s (1998) community-based surveys in theStates of Tamil Nadu and Uttar Pradesh show that women have higher odds of a “non-live-birthpregnancy” (conditioned on their total number of children ever born) if they report they have everbeen “beaten up” by their spouses. Consequently, the present investigation extends Jejeebhoy’sfindings to the national level in India.The second major finding is that conjugal physical assaults on mothers are not associatedwith a higher rate of mortality among their infants. Rather, our data show that when physicalviolence against women threatens the lives of their children, it does so while they are still in utero.However, husbands who physically assault their wives may also batter their young children withsometimes - fatal consequences. This possibility must be left for future research to explore.

More Infant and Fetal Deaths among Battered Women? Evidence from India 11This study holds implications for future research and for public health policy. The NFHSquestionnaire did not ask the regularity of conjugal assault, the location or severity of any injurysustained from it, nor directly connect the assault to a particular pregnancy and its outcome.However, these questions are difficult to administer in a face-to-face survey interview, becausedisclosures can both embarrass the respondent and put her at further physical risk if other householdmembers are present and overhear. Therefore, conjugal assault is likely underreported in the NFHSsurvey. Future researchers should take special care in asking detailed questions about physicalinjuries women suffer at home by posing these questions to only one woman respondent perhousehold and only when the interviewer and the respondent are alone or by allowing these injuriesto be reported without attributing responsibility for them. In addition, health clinics in India cancombat anti-woman violence by checking for physical evidence of assault, counseling assaultedwomen in methods of self defense, or providing safe havens.

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