J Fam Viol (2016) 31:15–25
DOI 10.1007/s10896-015-9742-6
ORIGINAL ARTICLE
Domestic Violence Against Rural Women in Pakistan: An Issue
of Health and Human Rights
Rubeena Zakar 1 & Muhammad Z. Zakar 1 &
Safdar Abbas 1
Published online: 11 June 2015
# Springer Science+Business Media New York 2015
Abstract Pakistani women living in rural areas are particularly vulnerable to violence because of their relatively weaker
social position and lack of awareness about their legal rights.
We investigated domestic violence against rural women and
its association with women’s health. A cross-sectional survey
was conducted from Rural Health Center of five selected districts by conducting face-to-face interviews from 490 randomly selected women of reproductive age. The data showed that
about 65 % of the interviewed women had experienced different types of violence, with psychological violence being the
most common. Multivariate logistic regression analysis
showed that women’s low education, low income, and marriage at an early age were significantly associated with domestic violence. Additionally, Domestic violence was significantly associated with poor mental and reproductive health. These
findings may be useful in developing public health programs
to address domestic violence against rural women.
autonomy of women (Diop-Sidibé et al. 2006). Furthermore,
it adversely affects women’s self-esteem and quality of life
(Campbell 2002; Heise et al. 1999). Research suggests that
violence significantly increases women’s morbidity (Heise
et al. 1999), psychological complications, depression, and injuries (Campbell 2002). DV is also instrumental in increasing
sexually transmitted diseases, unintended pregnancy
(Gazmararian et al. 2000), and denial of women’s right to
use contraceptives (Coker 2007; Moore et al. 2010). The term
BDV^ includes psychological (acts of humiliation, yelling,
shouting, and intimidation), physical (acts of slapping, hitting,
beating, strangulation, burning, and threats with a knife or
weapon), and sexual violence (acts of non-consensual or
forced sexual intercourse) by a husband toward his wife
(Garcia-Moreno et al. 2005).
Domestic Violence against Rural Women
Keywords Human rights violation . Women’s mental health .
Psychological violence . Risk factors for domestic violence
Domestic violence (DV) against women has grave implications for the physical and psychological well-being of women
(Campbell 2002). Of late, the international community has
recognized that DV is a serious violation of human rights,
and directly damages general health and wellbeing (Hidrobo
and Fernald 2013; Shuib et al. 2013) and reproductive
* Rubeena Zakar
rubeena499@hotmail.com
1
Department of Public Health, Institute of Social and Cultural Studies,
University of the Punjab, Lahore, Pakistan
About 63 % of the Pakistani population lives in rural areas
(World Bank 2011) and women living in rural areas are at
increased risk of DV than their urban counterparts (Koenig
et al. 2003; Krishnan et al. 2001). . Various factors likely
influence the etiology of DV in married rural women, including intrapersonal, interpersonal, and sociological factors. These factors include rural women’s relatively weaker social position, low literacy rate, and lower level of awareness about
their social and legal rights (Jejeebhoy 1998; Peek-Asa et al.
2011). Due to the structural disadvantages, rural women lack
capacity building opportunities and access to economic resources and are usually dependent on men for their day-today subsistence (Koenig et al. 2003). It is also reported that
rural women are usually physically isolated from the rest of
society and lack community support and legal services if they
were to become victims of DV (Krishnan et al. 2001).
16
Historically, patriarchal norms and tendencies of hegemonic masculinity are stronger in rural areas than urban centers
(Zakar 2012; Riddell et al. 2009). Generally, rural women are
treated as subordinate to men and perceived to be the custodians of family honor (Critelli 2010). Furthermore, men consider it their responsibility to ensure the subservience of women (Zakar et al. 2012).
Additionally, in rural areas, societal acceptance of DV
against women appears relatively higher, particularly in cases
of a woman’s Bdisobedience^, suspected adultery, or showing
disrespect to her in-laws (Bogal-Allbritten and Daughaday
1990). Because of societal acceptance of violence in general,
males in rural areas have a childhood history of physical abuse
and neglect (Khodarahimi 2014) and they use this violence in
adulthood to resolve their conflicts, especially against their
wives. Furthermore, the socioeconomic status of women in
Pakistan is low, particularly in rural areas. Overall, women
in Pakistan face various types of discrimination. The Global
Gender Gap Report (2013) showed that Pakistan is ranked at
135 out of 136 countries experiencing worst gender disparities
(Hausmann et al. 2013).
Pakistan has an extensive legal framework comprising of
various legal instruments to define and combat violence against
women (VAW), particularly DV. The legal framework for protection of women from violence ranges from Constitutional
provisions to a Penal Code to various laws promulgated by
the Government. In this regard, the Domestic Violence (Prevention & Protection) Act 2012 is a significant attempt to recognize
domestic violence against women, children, and other vulnerable persons as a criminal and punishable offence. The Act cites
physical, sexual, psychological, and economic abuse as punishable offences. Though in Pakistan, legal protection is available
to women against this violation, these laws are not implemented
in their true sense because of structural and administrative constraints in the criminal justice system (Critelli 2010).
J Fam Viol (2016) 31:15–25
humiliated and suffer from low self-esteem, but may also alienate her from the community (Koenig et al. 2003). In rural areas,
women’s limited ownership of their bodies could be an obvious
hurdle for women exercising their reproductive and bodily
rights (Amado 2003; Zakar et al. 2012). Arguably, sexuality
and body rights are among the major human rights and these
rights are based on the principal of equality between the couple
(Frohmader and Ortoleva 2013). The realization of these rights
is directly related with women’s empowerment (Amado 2003).
Furthermore, living under the threat of violence potentially
weakens women’s familial bonds and erodes their social capital
(Zakar et al. 2012). Consequently, their ability to resist violence
and mobilize social resources for their safety gets impaired
(Zakar et al. 2012). It makes them even weaker and more vulnerable to violence at the hands of their husbands or other
family members. This concept has been schematically presented in Fig. 1.
Generally, in developing countries, there is a dearth of scientific exploration of DV in both urban and rural areas. Despite the fact that 63 % of the population lives in rural areas
(World Bank 2011), there is a scarcity of research which exclusively focuses on the nexuses of DV, women’s health, and
violation of human rights regarding rural women. Though
recently the issue has been proactively debated at both political and social levels, it is not yet appropriately recognized as a
public health and human rights issue in Pakistan (Zakar et al.
2012). Given this backdrop, the present study intends to determine factors associated with experiences of DV among rural married women and its association with women’s mental
and reproductive health outcomes within the context of their
human and health rights.
Materials and Methods
Study Settings
Domestic Violence: Intersection of Health
and Human Rights
Health of an individual is recognized as a basic right by the
World Health Organization and it is the responsibility of a state
to ensure protection of every individual’s health (World Health
Organization 2013). The health of an individual cannot be
protected if the individual faces any kind of violence, be it
within the domestic sphere or outside home (Zakar 2012). Violence committed in the domestic sphere is even more harmful
and permanently damaging for women because the power
equation is highly tilted in the favor of men (Zakar et al.
2012). In rural areas, where violence is usually socially tolerated and rarely reported, women have less capacity to Bcontrol^
the damage done by violence (Zakar et al. 2012). Domestic
Violence not only hurts the dignity of woman, as she may feel
The health centers based cross sectional survey was conducted
between July 2012 and December 2012 in five comparably
similar districts from the upper (Gujranwala, Sialkot) and Central (Sargodha, Sheikhupura and Kasur) regions of the Punjab
province. These districts were purposively selected because
they share similar socio-demographic characteristics including
total population, male to female ratio, literacy rate, labour force
participation, participation of people in agriculture, and socioeconomic development (Health Department 2010–13). Selection of these districts can provide a snapshot of rural women
experiencing violence and human rights violations.
Selection of Respondents
Keeping in view relevant cultural and ethical issues, Rural
Health Centers (RHC) were considered to be the most
J Fam Viol (2016) 31:15–25
17
Fig. 1 Domestic violence against
rural women as an issue of human
rights violation
Violation of Reproductive Health
Rights
Unwanted pregnancy
Poor pregnancy outcome
Sexually transmitted diseases
Denial of use of contraceptives
Domestic
violence
against rural
women
Violation of Bodily Rights
Damage to bodily integrity
Limited choices of reproduction
Being unable to secure against violent
assault
Damage to psychological health
Damage to emotional stability
Violence as a
violation
of health and
human rights
Violation of Social Rights
Denial of legal capacity and decision
making
low self-esteem and confidence
Restricted mobility
Restricted ability to use health care
resources
Lack of access to justice
appropriate locations for obtaining access to rural women and
interviewing them in isolation. The centers helped to ensure
the privacy and safety of both interviewers and interviewees.
This was particularly essential given the sensitivity of the topic of DV and that rural women tend to live in joint family
systems where strong patriarchal forces would not allow them
to venture outside the home and participate in any research
activity. Keeping these limitations in view, researchers
approached rural women in RHCs and each interview was
conducted by female researchers.
Rural Health Centers are established in each district at
tehsil and sub tehsil level. On average, each RHC has 10–20
inpatients beds and serves a catchment population of 100,000
people per year. Rural Health Centers have strong linkages
with indigenous communities which are maintained primarily
with the help of Lady Health Workers (LHWs). For the selection of RHCs, the list of RHCs was obtained from the department of health, Government of the Punjab (2012). Out of a
total of 51 RHCs in five districts, 20 (40 %) RHCs were
randomly selected. Based on the previous experience of the
first researcher in research of a similar nature (Zakar 2012;
Zakar et al. 2012), we calculated the sample size by using
50 % prevalence of DV in the study areas. The degree of
precision Bd^ for p=0.1 to 0.8 was defined as d=0.05, according to desired confidence level of 5 %, Z=1.96. According to
n=(z)2 p (1-p)/d2 the sample size was calculated as 384 (when
P=0.5 and d=0.05). Subsequently, a sample of 384 respondents was used to obtain a confidence interval of +/− 5 %
around a prevalence estimate of 50 %. Considering the assumed non-response rate of 40 %, the initial sample size was
534 before the start of field research (Table 1).
By using a structured interview schedule, we conducted
face-to-face interviews with randomly selected rural women
of reproductive age (15–49 years). By using a systematic random technique, we started the interview at a random point of
the fifth woman in the queue waiting for her turn for a checkup by the doctor, and every third woman was invited to participate in the study. In seven cases, women could not complete the interview because of their turn for check-up. In almost 10 % of cases, women were unwilling to participate in
the interview due to one or the other reasons.
Tools of Data Collection
To collect quantitative information, a structured interview
schedule was developed in English and it was translated into
Punjabi (local language). The structure of the interview schedule was 1) socio-demographic characteristics; 2) women’s experiences of violence; and 3) women’s health conditions; any
history of injury, mental and reproductive health complaints
(Zakar 2012; Zakar et al. 2012; Zakar et al. 2013).
The women’s DVexperience during the last 12 months and
marital lifetime was used as a dependent variable. The type
and intensity of DV were measured by a series of questions
(adopted from revised Conflict Tactic Scale type-2 (CTS-2)
(Straus et al. 1996). The women were asked about the occurrence of both lifetime and current (occurring in the last
12 months preceding the survey) violence from their husbands. The women who reported history of current violence
were asked about the nature of any resulting injuries.
On the basis of our previous experiences (Zakar et al.
2012), we used a 12-item symptom list to measure the
18
Table 1 Selection of sample at
district and RHC level
J Fam Viol (2016) 31:15–25
District
Gujranwala
Kasur
Sheikhupura
Sialkot
RHCs
40 % sample
Round off (Number of RHCs)
Number of Respondents
9
3.6
4
96
12
4.8
5
120
9
7
3.6
2.8
4
3
96
78
Sargodha
14
5.6
6
144
Total
51
20.4
20
534
reproductive health status of women. This list was comprised
of reproductive health related symptoms including foul smelling vaginal discharge, difficult urination, excessive pelvic
pain, diagnosed/treated sexually transmitted infections, loss
of libido, itching/irritation in the vaginal area, history of bleeding or complication during last pregnancy, or any other gynecologic problem during the last 6 months before the survey
with response category of Bno’ or Byes^. The Cronbach’s Alpha for this scale was 0.86. For measuring women’s mental
health, the 20-items Self-Reporting Questionnaire (WHO
1994) was used, which included Byes^ and Bno^ response
categories.
Keeping in mind the cultural norms and gender sensitivities
of Pakistani society, we used three trained female interviewers
with master’s degrees in Gender Studies/Social Anthropology
for the field research. Since some of the rural areas in the study
setting exhibited strict gender segregation codes, the interviewers were provided a special training to ensure their own
and the respondents’ safety and security. Moreover, given that
the study explores the issue of DV, it was essential to consider
all ethical issues as well as those related to the safety of participants and others who assisted the study. In this regard, the
World Health Organization’s Ethical and Safety Recommendations for Research on Domestic Violence (WHO 2001)
were followed throughout the whole research process.
For the participants’ safety, they were approached in outpatient departments, where most of them were alone and
away from other family members. Following the WHO
guidelines, the study was introduced as a study on women’s
health and family relations instead of study on DV. We
preferred to interview women in a separate room or in a
place where there would be no outside interruption. In some
cases, the interview process was interrupted by a relative or
female companion, in which case a dummy questionnaire
was used to ensure confidentiality. Of note, this dummy
questionnaire contained questions on child health and vaccinations, etc. Appropriate informed oral consent was taken
before conducting the interview. No financial compensation was provided; however, those women who needed
counseling or treatment services were referred to relevant
sources of assistance. The study protocols were reviewed
and approved by the Institutional Review Board of the University of the Punjab.
Data Analysis
For analytical purposes, the reproductive health status variable
was dichotomized as Bgood^ (0–9 score) and Bpoor^ (10–12
score) reproductive health (Zakar 2012). Similarly, the mental
health variable was dichotomized into Bgood^ (0–7 score) and
Bpoor^ (8–20 score) mental health. Both bivariate and multivariable logistic regression analyses were used to identify the
determinants of DVand association between DVand women’s
mental and reproductive health dimensions (such as current
use of contraceptives, planned pregnancy, use of antenatal
care, history of abortion, and self-reported reproductive health
status). First, multicollinearity between the variables was
checked, and highly correlated variables were not entered in
the logistic model. Only those variables having a significance
level of 0.2 at bivariate analysis were entered into multivariable logistic regression analysis. Statistical Package for the
Social Sciences, version 19 (SPSS) was used for statistical
analysis and p<0.05 was considered a statistically significant
level.
Results
We approached 534 women for interviews, but only 497 were
willing to participate in the study. In the final analysis, 490
women were included as seven interviews were incomplete.
The mean age of the respondents was 31.1 years (SD±7.54,
range 15–49) and their husbands’ was 37.9 years (SD±9.11,
range 22–70). Out of 490 respondents, 114 (23 %) were in the
range of 15–24 years and 201 (41 %) were in the age range of
25–34 years. In terms of education, 153 (31.2 %) never
attended school; only 102 (20.8 %) completed 10 years of
schooling. A huge majority (80 %) were housewives, and only
97 (19.8 %) were employed. The main occupation of
employed women included farmers, laborers, school teachers,
and lady health workers. About half (52.7 %) reported monthly familial income less than 15,000 rupees (around 151 US$).
A little less than a half of the women (46.5 %) reported marriage duration of more than 9 years and 52.7 % had more than
three children. A majority (62 %) of the women received
antenatal care during their last pregnancy and only 28.6 %
were currently using any contraceptive method (see Table 2).
J Fam Viol (2016) 31:15–25
Table 2
19
Socio-demographic characteristics of respondents (N=490)
Variables
f (%)
Respondents characteristics
Age
15–24 years
25–34 years
114 (23.3)
201 (41.0)
Table 2 (continued)
Variables
f (%)
Last pregnancy was planned
Yes
205 (41.8)
No
175 (35.7)
Current use of any contraceptive e
Yes
No schooling
153 (31.2)
No
History of abortion
Five years of schooling
Eight years of schooling
139 (28.4)
96 (19.6)
≥35 years
Education
Ten years of schooling
Employment status
Yes
No
Husband’s characteristics
102 (20.8)
Yes
No
Good
Poor
Self-reported mental health
Good
Poor
Age
22–34 years
203 (41.4)
35–44 years
156 (31.8)
140 (28.6)
318 (64.9)
146 (29.8)
344 (70.2)
Self-reported reproductive health
97 (19.8)
393 (80.2)
268 (41.8)
a
374 (76.3)
116 (23.7)
258 (52.7)
232 (47.3)
Values are given as number (percentage)
b
US $1 was equivalent to 100 Pakistani rupees at the time of present
study
>44 years
Education
No schooling
Five years of schooling
131 (26.7)
Eight years of schooling
Ten years of schooling
Familial monthly income b
<15 000 rupees
≥15 000 rupees
Number of children
142 (29.0)
171 (34.9)
d
Including widowed, divorced, and separated women
e
The total percentage is not 100 % because of missing values
258 (52.7)
232 (47.3)
On the basis of women’s self-reported health complaints, we
found that about 47 % had poor mental health and about 24 %
of the women had poor reproductive health.
Out of 480 respondents, about 76 % experienced current
psychological violence (verbal abuse and physical threats) and
88 % experienced lifetime psychological violence at least
once. About 30 % of the women reported a history of lifetime
physical violence, while 16 % reported current physical violence and 44 % reported experiencing lifetime sexual violence
(see Table 3).
Overall, 16.5 % of women who reported DV (either threats
or physical violence) during the previous 12 months suffered
related injuries (see Table 4). About 14 % of women reported
physical pain lasting more than 1 day and 4 % women reported a history of broken bones due to DV. About 7 % of women
required medical attention for their injuries at least once during the last 12 months preceding the survey.
c
64 (13.1)
113 (23.1)
≤3
4–6
>6
Duration of marriage, years
<5 years
232 (47.3)
232 (47.3)
98 (20.0)
5–9 years
>9 years
Participant’s age at first marriage
<18 years
119 (24.3)
228 (46.5)
≥18 years
Type of marriage
Married without consent
Married with consent
Family system
Joint
Nuclear
Marital status
Currently married
Currently not in marital relationship d
Received prenatal care for last pregnancy e
Yes
No
143 (29.2)
148 (30.2)
342 (69.8)
256 (52.2)
234 (47.8)
353 (72.0)
137 (28.0)
453 (92.4)
37 (8.6)
305 (62.2)
166 (33.9)
The women were living together with their mother- and father-in-laws,
brothers and sisters of their husbands under 1 roof and shared the same
kitchen
Multivariable Analysis
We have presented the results of multivariable analysis in
Table 5. The data suggested that education was a significant
predictor of psychological and physical violence. The respondents without any formal schooling were 6.06 times more
likely than their educated counterparts (10 years of schooling)
20
J Fam Viol (2016) 31:15–25
Table 3 Frequency of lifetime and current domestic violence against
rural women (n=490)
Type of domestic violence
% reported
Lifetime
In the last 12 months
Verbal abuse
61.1
56.1
Physical threats
26.9
20.0
Physical violence
Sexual violence
30.2
43.9
16.3
28.0
to have experienced psychological violence, 5.42 times more
likely to have experienced physical violence, and 1.38 times
more likely to have been sexually abused by their husbands
(see Table 5). Data also showed that the number of children
had no significant association with the risk of experiencing
psychological or sexual violence except physical violence
(AOR 2.92, 95 % CI 1.25–4.88). Nonetheless, young age at
marriage was a significant predictor of physical violence. The
respondents who married at a younger age were more likely to
experience physical violence (AOR 2.47, 95 % CI 1.09–5.62)
than the women who were married later.
Multivariable logistic regression analysis presented in Table 6 shows that the women who experienced current sexual
violence were more likely to report non-use of contraceptives
(Adjusted odds ratio [AOR] 1.71, 95 %CI 1.0–3.07), poor
antenatal care (AOR 1.97, 95 %CI 1.26–3.02), unplanned
pregnancies (AOR 3.71, 95 %CI 2.26–6.09), and poor selfreported reproductive health status (AOR1.92, 95 %CI 1.16–
3.02) as compared to the respondents who did not experience
sexual violence after adjusting for respondent’s age, level of
education and familial monthly income. Of note, we found
similar results in our previous research on urban women
(Zakar et al. 2012; Zakar 2012).
Similarly, the women who experienced current physical violence were more likely to report poor antenatal care (AOR
1.89, 95 %CI 1.19–2.98), unplanned pregnancies (AOR 2.27,
95 %CI 1.40–3.68), and poor self-reported reproductive health
status (AOR 2.03, 95 %CI 1.21–2.91) (Table 6).
Table 7 shows that the exposure to current psychological
(OR 1.52, 95 % CI 1.02–2.27), lifetime, physical (OR 2.63,
Table 4 Injuries to women resulting from domestic violence in past
12 months (N=101)
Type of injury
% of Women reporting injury
Any injury
Physical pain lasting more than one day
Sprain, bruise or cut
Broken bone
Required medical attention
16.5
13.9
7.3
4.1
7.6
95 % CI 1.71–4.06), and current sexual violence (OR 2.05,
95 % CI 1.35–3.10) remained significant independent predictors of mental health morbidity after adjusting for respondents’ age, education, and monthly familial income.
Discussion
Our study revealed that psychological violence was the most
occurring type of violence followed by sexual and physical
violence. Prevalence of DV, especially psychological violence, in Pakistani rural areas suggests that violence is normalized in women’s marital life as a routine matter (UN WOMEN
2014) and is not considered a form of violence. In Pakistani
rural areas, psychological violence is institutionalized through
family structures, cultural and religious traditions, and is considered a widely accepted method for controlling women and
maintaining men’s supremacy over women (UN Women
2014).
Determinants of Domestic Violence
The likelihood of rural women to experience DV is predicted
by a complex web of variables which are often correlated with
each other (Koenig et al. 2003). Results of the present study
showed that higher level of education was inversely proportional to current DV. This is consistent with findings of a
recent study from Pakistan which suggested that women’s
higher level of education decreases the occurrence of DV (National Institute of Population Studies and Macro International
2013). The Findings of this research reinforced the assumption that education is the best investment to empower women
and save them from violence (Koenig et al. 2003). Similarly,
Gracia and Herrero (2006) concluded that economic and social empowerment of women can contribute to reductions in
DV.
Findings of the present study further demonstrated that low
socio-economic status was a strong predicator for rural women to become victims of psychological, physical, and sexual
violence. It has been reported that because of massive rural
poverty in Pakistan, rural families frequently endure periods
of economic stress (Bernston 1993). Therefore, one explanation for the higher occurrence of DV in low-income families
could be the increased level of stress in spousal relations
caused by financial constraints (Ashwin and Lytkina 2004).
For men in these situations, violence may not only be a way to
obscure their misbehaviour (Saigol 2011) but also to restate
their authority under the influence of patriarchal norms
(Stickley et al. 2008). Studies from rural areas of south Asian
countries, including Pakistan (Zakar 2012), Bangladesh
(Koenig et al. 2003), India (Raj et al. 2009), and Afghanistan
(Niaz 2003), further indicated that lower level of education,
lower socioeconomic status, misinterpretation of religion, and
J Fam Viol (2016) 31:15–25
Table 5 factors associated with
current psychological, physical
and sexual violence (Multiple
logistic regression employed
separately with each type of
violence, N=490)
21
Characteristics
Marriage duration
<5 years
5–9 years
>9 years
Psychological
violence (n=287)
OR (95 % CI)
Physical violence
(n=80)
OR (95 % CI)
Sexual violence
(n=137)
OR (95 % CI)
1.52 (0.77–3.02)
–
0.67 (.41–1.10)
1.08 (0.59–1.96)
1.00
1.06 (0.56–1.71)
1.00
Age at marriage
<18 years
>18 years
1.16 (0.68–1.99)
1.00
3.15 (1.79–
5.53)***
1.00
1.00
1.00
1.37 (0.77–2.42)
2.47 (1.09–5.62)*
1.07 (0.66–1.74)
6.06 (3.67–11.44)***
5.4 (2.78–10.48)***
1.38 (0.77–2.47)
5 years of schooling
8 years of schooling
4.42 (2.24–8.74)***
1.88 (0.98-3.60)
2.21 (1.16–4.22)*
1.59 (0.99–1.89)
1.40 (0.03–2.42)
1.38 (0.05–3.20)
10 years of schooling
1.00
1.00
1.00
Up to15,000 Rs.
>15,000 Rs.
Number of children
1.69 (1.02–2.81)*
1.00
2.92 (1.42–6.09)**
1.00
1.98 (1.08–3.09)*
1.00
>6
4–6
≤3
Type of marriage
Married without consent
1.36 (0.74–2.49)
1.47 (0.67–3.21)
2.47 (1.25–4.88)**
2.37 (1.05–5.32)*
1.33 (0.67–2.36)
1.14 (0.27–2.00)
1.00
1.00
1.00
1.09 (0.65–1.99)
1.11 (0.62–3.08)
1.06 (0.69–4.02)
1.00
1.00
1.00
Employment status
Employed
Unemployed
Education
No Schooling
1.21 (0.71–1.92)
Familial monthly income
Married with consent
1.00=Reference category
OR Odds ratio, CI Confidence interval
*p<0.05. **p<0.01. ***p<0.001
poverty are significantly associated with higher risks of DV
against rural women.
Due to no or low level of education, a vast majority of
women in our study had no paid jobs. The data revealed that
only 20 % of women were involved in paid jobs – mostly in
the agriculture sector. Results of the present study revealed
that women’s unemployment increased the likelihood of physical violence whereas employment status did not appear to be
a strong predictor of psychological and sexual violence. Thus,
women’s involvement in paid work in fields and control over
farm resources may decrease the chances of physical violence
(Riddell et al. 2009). It has been found that financial autonomy of women improves their reproductive choices, household
decision-making, and self-esteem and is expected to alleviate
financial hindrances as well as contribute to a reduction in DV
against women (Koenig et al. 2003).
In the present study, marriage at an early age was also found
to be a significant predictor of domestic violence against rural
women. Marriages at an early age are a common practice in
Southeast Asian countries, particularly in Pakistan where
daughters are considered a liability and parents want to dispose
of them as early as possible (Nasrullah et al. 2014; Raj et al.
2009). Child marriage often results in early pregnancy, little
education, and social isolation reinforcing the feminization of
poverty (Raj et al. 2009; Unicef 2009). Girls married at a younger age possess little power in relation to their husbands and inlaws, therefore their vulnerability to be abused in the husband’s
home increases to a great extent (HRCP 2012; ICRW 2006;
Jejeebhoy 1998). Nonetheless, our data did not provide any
evidence of a significant association between DV and whether
the woman had initially consented to the marriage or not.
Domestic Violence and Women’s Health
The present study supports the assumption that women victims of DV are less likely to use contraceptives (Hindin and
22
J Fam Viol (2016) 31:15–25
Table 6 Association between
different types of current
domestic violence and
reproductive health dimensions
(Multivariable logistic regression
employed separately with each
type of violence N=490)
Variables
Psychological violence (n=287)
AOR (95 % CI)
Use of CMs
No
1.52 (1.01–2.20)*
Yes
1.00
Received antenatal care during last pregnancy
No
Yes
History of abortion
Yes
No
Physical violence (n=80)
AOR (95 % CI)
Sexual violence (n=137)
AOR (95 % CI)
1.57 (0.88–2.82)
1.71 (1.05–3.07)*
1.00
1.00
2.91 (1.77–4.78)
1.89 (1.19–2.98)**
1.97 (1.26–3.02)**
1.00
1.00
1.00
1.52 (0.89–2.64)
1.00
1.07 (0.67–1.71)
1.00
1.06 (0.69–1.64)
1.00
Pregnancies in last 5 years
Unplanned
1.34 (0.87–2.07)
Planned
1.00
Reproductive health status
Poor
Good
2.41 (1.32––5.92)**
1.00
2.27 (1.40–3.68)**
3.71 (2.26–6.09)***
1.00
1.00
2.03 (1.21–2.91)**
1.00
1.92 (1.16–3.02)*
1.00
Multivariable logistic regression analysis was carried out to obtain adjusted odds ratio after controlling for
respondents’ age, education and family monthly income
Abbreviations: 1 = Reference category; AOR adjusted odds ratio, CI confidence interval, CM contraceptive
method
*p<0.05. **p<0.01. ***p<0.0001
Table 7 Association
between mental health
and experience of current
and lifetime
psychological, physical,
and sexual violence (N=
490)
Variables
Mental health
AOR (95 % CI)
Current psychological violence
No
1.00
Yes
1.52 (1.02–2.27)*
Lifetime psychological violence
No
1.00
Yes
1.69 (1.04–2.72)*
Current physical violence
No
1.00
Yes
1.58 (0.95–2.65)
Lifetime physical violence
No
1.00
Yes
2.63 (1.71–4.06)***
Current sexual violence
No
1.00
Yes
2.05 (1.35–3.10)**
Lifetime sexual violence
No
Yes
1.00
1.48 (0.96–1.86)
Abbreviations: 1, reference category; AOR
adjusted odds ratio, CI confidence interval
a
Multivariate logistic regression analysis
was carried out to obtain the AOR after
controlling for participants’ age, education, and family monthly income
p<0.05. **p<0.01. ***p<0.0001
Adair 2002; Silverman et al. 2007; Wilson-Williams et al.
2008) because of poor reproductive health related spousal
communication (Fikree et al. 2001) and presumably noncooperative behavior on the part of the husbands. Men’s increased desire for children, culturally approved masculinity,
and propensity to control wives may be the reasons behind
men’s behavior in these cases (Ali and Gavino 2008).
The results of our study demonstrated that women who experienced DV were less likely to use antenatal care services.
Antenatal care is considered as the first step towards protecting
the health of mothers and the newborn (Roy et al. 2013). The
obvious reasons of low antenatal care could be lack of financial
and logistic support, lower level of education, and a male dominated patriarchal system widely prevailing in Pakistani society
(Alam et al. 2014). Furthermore, women’s access to and use of
reproductive health-care services are determined by a set of
gender norms, such as their freedom to travel, and their autonomy in decision-making in matters relating to reproductive health
(Mumtaz and Salway 2007). In some circumstances, non-usage
of antenatal care could potentially lead to maternal and infant
morbidity and mortality (Finlayson and Downe 2013).
Findings of our study revealed that only the experiences of
psychological violence were moderately associated with a history of abortion. Contrary to the other studies (Fikree et al.
2001; Polis et al. 2009), our study did not provide evidence of
an association between physical and sexual violence and a
history of abortion. Arguably, this may be the case because
women in violent relationships are more likely to conceal the
J Fam Viol (2016) 31:15–25
termination of pregnancy from their partner than those who do
not suffer violence (Hall et al. 2014). Moreover, it has been
found that women in abortion research studies usually do not
report DV more frequently as compared to women in contraceptive or other gynecologic studies (Kazi et al. 2008). Further
research is needed to explore the predictors of abortion in rural
Pakistani society.
Consistent with findings of other studies conducted in developed (Cripe et al. 2008) and developing countries (Pallitto
et al. 2005), the present study found that the likelihood of
unplanned pregnancy was higher among abused women. Rural women likely have less reproductive autonomy, which
leads to low use of contraceptives. The male dominated
mindset, which still prevails in rural areas, also tends to govern the bodily rights of women by considering them their
property (Saigol 2011).
The present research found that women who were victims
of all three types of violence showed poor self-reported reproductive health than women who had not experienced violence.
This finding is consistent with other studies which found that
DV has significant negative implications for women’s reproductive health (Campbell 2002; Wilson-Williams et al. 2008).
It is argued that improved socio-economic status of rural
women is a prerequisite to improve their reproductive health
status in Pakistan (Fatmi and Avan 2002).
This research also showed that women who had experienced
current and lifetime psychological, physical, and sexual violence
reported poor mental health. This finding is consistent with the
results of other studies which found that women’s experiences of
physical (Ayub et al. 2009; Fikree and Bhatti 1999), psychological (Ayub et al. 2009; Coker et al. 2007), and sexual violence
(Basile et al. 2004; Kumar et al. 2005) were strongly associated
with mental health morbidity among abused women.
The major limitations of the present study include the use
of self-report measures of health and the fact that we did not
confirm these health outcomes by using clinical tests. Secondly, the cross-sectional design was a limitation, as it does not
portray the causal relationship between DV and women’s
health status. Another limitation is the health center-based
recruitment of respondents, as it may have excluded women
who do not have medical problems, women experiencing DV
who are not allowed to seek healthcare, and women who use
traditional medicine. Furthermore, due to the scarcity of human and financial resources, districts from southern Punjab
could not be included in the sample. Nonetheless, this study
was a significant contribution in the field of violence research
in the rural areas of Pakistan.
Conclusion
This study concludes that rural women living in poverty, without formal education, and married at young age are more
23
vulnerable to DV. These women are more likely to experience
unplanned pregnancies, less antenatal visits, and poor selfreported mental and reproductive health. Our study shows that
DV is not only a social issue, but also a grave public health
concern and human rights violation. This situation in rural
areas suggests that DV is deeply embedded in the patriarchal
structure of society, which keeps women at a subordinate position in power relations. There is a need for comprehensive
strategies to empower women through enhancing their education and capabilities so that they can improve their socioeconomic status. Additionally, future research, particularly qualitative and longitudinal research, is needed to understand the
influence of rural culture and context on women’s experiences
of DV. Uplift.
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