Intimate Partner Violence and Associated Factors Among Pregnant Women in the Conflicted Northeast Ethiopia: A Cross‐Sectional Study

Abstract

ABSTRACT

Background and Aims

Intimate partner violence (IPV), perpetrated by male partners, inflicts physical, sexual, or psychological harm on women. During pregnancy, it becomes a significant public health concern and human rights violation, especially in conflict‐affected areas, affecting both mother and fetus negatively. Research in Ethiopia often overlooks nonusers of antenatal services, primarily conducted in health facilities. This study addresses this gap, aiming to provide valuable insights into community dynamics. Hence, this study assessed the prevalence and factors associated with IPV during pregnancy in the conflict‐affected district of Northeast Ethiopia.

Methods

A community‐based cross‐sectional study surveyed 603 postpartum women in the Argoba district, Amhara region Northeast Ethiopia, from March 26 to April 25, 2023, utilizing a multistage sampling technique. Data collection employed a structured questionnaire, coded, and entered into Epi‐data 4.6, then analyzed using SPSS version 26. Descriptive and Binary logistic regression analyses were conducted. Adjusted odds ratios were computed at a 95% confidence interval [CI], with a significance level set at p < 0.05. Model fit and multicollinearity were assessed for validity.

Result

The study found an overall prevalence of 45.1% (95% CI: 41.1–49.1) for IPV during pregnancy, with psychological violence being the most prevalent (38.0%), followed by physical (24.7%) and sexual violence (18.6%). Factors significantly associated with IPV included unwanted pregnancy (AOR = 1.94; 95% CI: 1.10–3.47), women's acceptance of violence (AOR = 2.39; 95% CI: 1.64–3.48), having a partner who chews khat (AOR = 1.99; 95% CI: 1.31–3.03), and spouse's engagement in multiple sexual partners (AOR = 1.63; 95% CI: 1.03–2.58).

Conclusion

The study's findings indicate a higher prevalence compared to others, with key factors including unwanted pregnancy, acceptance of violence, khat chewing, and multiple sexual partners. Recommendations include comprehensive sex education, awareness campaigns, relationship counseling, community engagement, improved healthcare access, stronger legal frameworks, and empowerment programs.

Abbreviations

• ANC
• antenatal care
• AOR
• adjusted odds ratio
• COR
• crude odds ratio
• IPV
• intimate partner violence
• IPVP
• intimate partner violence during pregnancy
• WHO
• World Health Organization

Introduction

Intimate partner violence (IPV) is a global public health crisis and a grave violation of basic human rights, affecting millions of women worldwide [1, 2]. IPV is perpetrated by current or former male partners, encompasses physical, sexual, or psychological harm, such as physical aggression, sexual coercion, and psychological abuse. Measuring IPV involves assessing experiences like physical assault, emotional abuse, and sexual coercion from partners [3, 4]. In the past decade, there's been a surge in efforts to prevent IPV against women, leading to the creation of numerous initiatives and policies. Notable among these are the Convention on the Elimination of All Forms of Discrimination Against Women (1979), the Declaration to End Violence Against Women (1993), and WHO's work on gender-based violence since 1996 [5–7]. WHO's development of strategies to prevent intimate partner and sexual violence against women in 2010 aligns with the recent SDG target 5.2 aimed at eliminating all forms of violence against women and girls [6, 8]. Ethiopia has intensified efforts to combat IPV, implementing gender-sensitive legislative measures, with global, Sub-Saharan African, and Ethiopian strategies addressing IPV during pregnancy [9].

Over 324,000 women estimated to endure IPV during pregnancy annually [10]. In Sub-Saharan Africa, particularly in Ethiopia, IPV during pregnancy is a pressing concern. Statistics reveal that one in three women globally has experienced IPV in their lifetime, with a prevalence of 37% in Africa alone [7, 11]. The high rate of IPV in Ethiopia is often attributed to community and societal acceptance, as evidenced by the 2016 Ethiopian Demographic and Health Survey, where a significant portion of victims remained silent about their abuse [12]. Prevalence rates during pregnancy vary widely, with physical IPV ranging from 2% to 35%, sexual violence from 9% to 40%, psychological violence from 22% to 65%, and an overall prevalence of IPV ranging from 0.9% to 59% [13–22].

IPV during pregnancy hinders women's access to maternal health services, potentially contributing to maternal mortality and morbidity [15, 23]. It adversely affects the health of the mother, fetus, and newborn, leading to injuries, chronic pain, mental health disorders, and poor utilization of healthcare services [11, 23–25]. IPV during pregnancy is associated with adverse pregnancy and birth outcomes, including fetal loss, low birth weight, premature birth, and newborn death [23, 25–27]. Identifying women at high risk of IPV during pregnancy is crucial for healthcare providers, emphasizing the need for raising awareness, promoting gender equality, and empowering women to seek support.

During pregnancy, IPV becomes particularly concerning due to increased relationship demands and resource needs. Risk factors such as age, education level, occupation, income, relationship status, pregnancy status/desire, acceptance of IPV, alcohol consumption, smoking, khat chewing, having many sexual partners, family size, number of children, extended family, and acceptance of IPV heighten the vulnerability to IPV during this crucial period. Social support has shown to mitigate antenatal distress among IPV-experiencing pregnant women, emphasizing the importance of addressing IPV within supportive networks [15, 17–20, 22, 25, 27–34].

Global initiatives like the sustainable development goals underscore the urgency of eliminating violence against women, urging screening for IPV during antenatal care visits as a preventive measure [35, 36]. Despite efforts by the Ethiopian government to promote gender equality and maternal health, challenges persist, necessitating tailored interventions. In Ethiopia, where institution-based studies often overlook vulnerable populations [16–18, 22, 31, 37]. This study in the Argoba district of Amhara region, aims to fill this gap, providing crucial insights to guide effective policy and intervention strategies to protect pregnant women from IPV and improve their overall well-being. Hence, this study the prevalence and factors associated with IPV during pregnancy in the conflict-affected district of Northeast Ethiopia.

Methods

Study Setting, Design and Period

The study took place in the conflict-affected Argoba district, situated in the South Wollo Zone of the Amhara region in Northeast Ethiopia. The district encompasses nine kebeles, predominantly rural, with limited healthcare facilities including three health centers, nine health posts, and two private clinics. Data from the Argoba Wereda health office indicates a population of 42,459, with around 22% females of reproductive age, and an estimated 1698 pregnancies annually, making up approximately 4% of the population (55). A community-based cross-sectional study was undertaken to assess the prevalence of IPV and its related factors among pregnant women, from March 26 to April 25, 2023.

Population

All women who gave birth in 6 months before data collection period and living in Argoba district in 2023 were the source populations. While, all women who gave birth in 6 months before data collection period, residing in the randomly selected Kebeles of Argoba district were the study population.

Inclusion criteria: Those delivered married women (with intimate partner) who have lived in the Argoba district for a minimum of 6 months were included in the study.

Exclusion criteria: Those delivered woman who had no intimate partner during the current pregnancy were excluded from the study.

Sample Size Determination

Both double and single population proportion formulas were used to estimate the sample size. The largest sample size was found by using a single population proportion formula by considering the following assumptions; 95% confidence interval [CI], 5% margin of error, design effect of 1.5, nonresponse rate (10%), and proportion of IPV (41.1%) taken from institution based study in Debre-Markos, Ethiopia [18] giving the final sample size of 614.

Sampling Procedure

A multistage sampling technique was used to choose the study participants from the target population. There are six subcities in Bahir-Dar city, and of these, two of the subcities were selected by lottery method. There are eight kebeles (the smallest administrative units) in these two subcities, and three of the kebeles were selected by lottery method. Then the sample size was proportionally allocated to the selected kebeles. Finally, a systematic random sampling technique was used to select the study participants. A multistage sampling technique was employed to select study participants. Initially, two urban kebeles (kebele01 and kebele 04) and one rural kebele (kebele07) were randomly chosen out of nine kebeles in the district using a lottery method. Subsequently, study participants were selected through simple random sampling using a computer generation technique, utilizing the Delivery/EPI registration of health extension workers as a sampling frame. In the district, there were 1250 delivered women, with 700 located in the three selected kebeles (kebele 01 = 264, kebele 04 = 229, and kebele 07 = 207). From the total of 700 illegible women, 614 participants were chosen through computer generation. Thus, a total of 614 women who had given birth within 6 months before the data collection period was enrolled in this study.

Study Variable

The dependent variable: IPV during pregnancy (Yes/No).

The independent variables were; women-related factors: age, education, occupation, own income, relationship status, residence, pregnancy nature/desire, and acceptance of IPV. Intimate partner-related factors: Age, education, occupation, own income, alcohol consumption habit, smoking habit, Khat chewing, and having multiple sexual partners. Family-related factors: Family size, number of children, presence of extended family, and monthly family income.

Data Collection Tool and Procedure

The data were collected through face-to-face interviews using a structured questionnaire derived from the WHO multicountry study on women's health and domestic violence against women, alongside insights from related literature reviews [2, 4, 16–19, 22, 38]. The questionnaire comprehensively covered variables concerning women, intimate partners, families, and questions on IPV. There were nine sociodemographic-related question, 11 intimate partner-related questions, five family-related questions, and four IPV-related questions. Initially prepared in English, the questionnaire was translated into Amharic, the local language, for cultural appropriateness and ease of understanding. To ensure consistency, the Amharic versions were then back-translated into English by language experts.

A team comprising four Bachelor of Science midwives and two Bachelor of Science nurses, overseen by two health officer supervisors, carried out data collection. All data collectors were female, facilitating open responses to sensitive issues. Respondents were approached with explanations about the study's objectives and the information required from them, ensuring confidentiality as no personal identifiers were collected. Upon completion, questionnaires were scrutinized for completeness and signed by the principal investigator.

To maintain data quality, rigorous training was provided to data collectors and supervisors a day before data collection. The questionnaire, administered in the native Amharic language, underwent pretesting on 31 delivered women, constituting 5% of the sample size, in Qalu district. Daily supervision was conducted by field supervisors, with regular meetings held among the principal investigator, data collectors, and supervisors to address any challenges encountered during data.

Measurement

Intimate partner: The male partner of the woman in a couple, either be a husband (legal or illegal), a fiancé, a boyfriend, or any male sexual partner who cohabit with the woman [4].

IPV during pregnancy present: Woman who reported as experienced at least one of the three types of violence (i.e., physical, sexual, and emotional violence) in her last pregnancy by her intimate partner classified as having experienced any IPV during the current pregnancy [4].

Emotional IPV during pregnancy: Defined as mothers experienced any of the following; have been insulted by husband by using abusive language that made feel bad, insulted in front of others, have been scared or intimidated on purpose, or have been threatened by husband with an object such as a stick, belt, knife, gun, and so on by a current partner/boyfriend during the current pregnancy [4].

Physical IPV during pregnancy: Defined as mothers experienced any of the followings; being slapped or having something thrown at her that could hurt her, being pushed or shoved, being hit with a fist or something else that could hurt, being kicked, dragged, being choked or burnt on purpose, and/or being threatened with/having, a gun, a knife, or another weapon used on her by a current intimate partner during the current pregnancy [4].

Sexual IPV during pregnancy: Defined as mothers experienced any of the followings; being physically forced to have sexual intercourse when she did not want to, having sexual intercourse because she was afraid of what her partner might do, and/or being forced to do something sexual that she found humiliating or degrading to her by an intimate partner during the current pregnancy [4].

Acceptance of IPV: Refers to the belief of a woman towards the cultural or societal thought of IPV is standard/normal [38].

Extended family: Any of the family members other than the biological (adopted) children of the couple, such as grandparents, parents, uncles, aunts, sisters, brothers or relatives of the male partner or the woman.

Presence of own income: The presence of any regular means of income belonging to each individual in a couple (i.e., the woman and the male partner each).

Substance use: If the intimate partner drinks alcohol or smokes cigarette or chew Khat at least once during the current pregnancy, considered as substance user.

Unemployed: The woman or her intimate partner who had no any occupation during the current pregnancy.

Kebele: The smallest administrative unit in Ethiopia government system.

Data Processing and Analysis

All questionnaires underwent coding and entry using EpiData 4.6 before exporting the data to Statistical Package for Social Science (SPSS) version 26 for analysis. Descriptive analysis was conducted, presenting findings through tables, graphs, frequencies, and textual summaries. Binary logistic regression was utilized, beginning with bivariable analysis to assess the association of each independent variable with the outcome variable, yielding crude odds ratios (COR) with 95% CI. Variables with “p < 0.20” in the bivariable analysis were included in multivariable logistic regression models to ascertain the effect of each independent variable while controlling for potential confounding. Significance was determined at “p < 0.05” in the multivariable analysis, generating adjusted odds ratios (AOR) with 95% CI to establish associations. Assessment for multicollinearity via variance inflation factor (VIF < 10) revealed no issues, and the Hosmer-Lemeshow test confirmed model fit (p = 0.313).

Ethical Approval and Consent to Participate

Ethical clearance was secured from the Bahir Dar University College of Medicine and Health Sciences Institutional Review Board (IRB) with Protocol number 696/2023. Additionally, permission letters were obtained from Amhara Public Health Institute (APHI), the South Wollo Health Department, Argoba district Health Office, and other relevant authorities to conduct the study. Written consent was obtained after explaining the benefits and risks in detail, with respondents informed of their right to refuse or discontinue the interview at any time. Data provided by participants were strictly utilized for research purposes and kept confidential, with individual identifiers removed and replaced by unique numbers to ensure anonymity. All data were securely entered into a password-protected computer system.

Results

Socio-Demographic Characteristics of Women

This study revealed that out of the 614 women, 603 were successfully interviewed, resulting in a response rate of 98.2%. Approximately half of the respondents (49.3%) fell within the age of 25–34 years, with a mean age of 27.8 (SD ± 6.2) years and an age range spanning from 17 to 45 years. The majority of the participants (93.9%) identified as Muslims, and a significant portion (71.8%) resided in rural areas. Regarding education, the majority of women (67.0%) had not received formal schooling, while more than half (59.0%) were engaged in farming occupations (Table 1).

Table 1 Socio-demographic characteristics of pregnant women in the Argoba district, Northeast Ethiopia, 2023 (N = 603).

Variables	Category	Frequency	Percentages
Age of women (years)	15–24	203	33.7
25–34	297	49.3
≥ 35	103	17.0
Religion	Orthodox	37	6.1
Muslim	566	93.9
Residence	Rural	433	71.8
Urban	170	28.2
Educational status of women	No formal education	404	67.0
Primary education	101	16.7
Secondary and above	98	16.3
Occupational status of women	Farmer	356	59.0
Unemployed	134	22.2
Merchant/daily laborer	66	11.0
Government/private employed	47	7.8
Have own income	No	424	70.3
Yes	179	29.7
Relationship status	Married	550	91.2
Unmarried	53	8.8
Nature/desire of pregnancy	Wanted	519	86.1
Unwanted	84	13.9
Acceptance of IPV	No	324	53.7
Yes	279	46.3

Participants Family and Intimate Partner's Characteristics

The majority of the participants' intimate partners (68.7%) were aged 30 and older. On average, the age of these intimate partners was 34 years (± 8.5), with ages ranging from 20 to 65 years old. A significant proportion of the partners (64.7%) had not received formal education, and the majority (72.1%) were engaged in farming activities. Additionally, over half of the partners (55.1%) reported a habit of khat chewing, while 31.0% reported a habit of cigarette smoking during the most recent pregnancy. Approximately 51.9% of the participants reported having a family size of 5 or more members. Every participant (100%) had at least one child, with a median monthly family income of 4000 Ethiopian birr (Table 2).

Table 2 Participants family and intimate partner characteristics in the Argoba district, Northeast Ethiopia, 2023 (N = 603).

Variables	Category	Frequency	Percentages
Age of partner (years)	20–29	189	31.3
≥ 30	414	68.7
Educational status of partner	No formal education	390	64.7
Primary education	97	16.1
Secondary and above	116	19.2
Occupational status of partner	Farmer	435	72.1
Unemployed	11	1.8
Merchant/daily laborer	78	12.9
Government/private employed	79	13.1
Partner have their own income	No	386	64.0
Yes	217	36.0
Alcohol drinking habit of partner	No	568	94.2
Yes	35	5.8
Cigarette smoking habit of partner	No	416	69.0
Yes	187	31.0
Khat chewing habit of partner	No	271	44.9
Yes	332	55.1
Had multiple sexual partner	No	467	77.4
Yes	136	22.6
Number of family members	≤ 4	290	48.1
≥ 5	313	51.9
Number of children	≤ 4	470	77.9
≥ 5	133	22.1
Extended family	No	541	89.7
Yes	62	10.3
Family average monthly income (ETB)	< 3000	138	22.9
≥ 3000	465	77.1

Prevalence and Types of IPV During Pregnancy

The overall prevalence of IPV during the present pregnancy stood at 45.1% (95% CI: 41.1–49.1) (Figure 1). Psychological violence emerged as the most prevalent form, followed by physical and sexual violence. Among all participants in the study, 38.0% (95% CI: 34.2–42.0) experienced psychological violence, 24.7% (95% CI: 20.9–28.0) experienced physical violence, and 18.6% (95% CI: 15.6–21.9) experienced sexual violence (Figure 1). The coexistence of various types of IPV (three-type, only two-type, and only one-type IPV) was also examined among participants (Figure 2). The coexistence of psychological and physical violence was more prevalent among the two-type IPV cases.

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Factors Associated With IPV

A bivariable and multivariable logistic regression analyses were conducted to pinpoint factors linked with IPV during pregnancy. In the bivariable analysis, various factors such as women's age, education level, occupation, relationship status, pregnancy intention, acceptance of IPV, partner's age, education level, occupation, smoking habits, khat chewing, partner's history of multiple sexual partners, family size, and presence of extended family were considered eligible variables for inclusion in the multivariable logistic regression analysis (p < 0.20).

In the multivariable analysis, factors significantly associated with IPV during pregnancy included pregnancy intention, acceptance of IPV, khat chewing by the partner, and partner's history of multiple sexual partners. The odds of experiencing any form of IPV during pregnancy were found to be twice as high among respondents with unwanted pregnancies compared to their counterparts (AOR = 1.94; 95% CI: 1.10–3.47). Women who accepted IPV were over two times more likely to experience IPV during pregnancy compared to those who did not accept it (AOR = 2.39; 95% CI: 1.64–3.48). Additionally, women whose partners chewed khat had double the odds of encountering IPV during pregnancy compared to those whose partners did not (AOR = 1.99; 95% CI: 1.31–3.03). Respondents whose partners had multiple sexual partners had a 1.63 times higher chance of experiencing IPV during pregnancy compared to their counterparts (AOR = 1.63; 95% CI: 1.03–2.58) (Table 3).

Table 3 Bivariable and multivariable logistic regression analysis of factors associated with intimate partner violence during pregnancy among women in the Argoba district, Northeast Ethiopia, 2023 (N = 603).

Variables	IPV	COR (95% CI)	AOR (95% CI)
Yes	No
Age of women (years)	15–24	83	120	1.01 (0.62–1.63)	1.65 (0.77–3.56)
25–34	147	150	1.42 (0.90–2.24)	1.36 (0.80–2.32)
≥ 35	42	61	1	1
Educational status of women	No formal education	200	204	1.85 (1.17–2.92)*	1.53 (0.75–3.12)
Primary education	38	63	1.14 (0.64–2.03)	1.02 (0.48–2.16)
Secondary and above	34	64	1	1
Occupational status of women	Farmer	172	184	1.51 (0.81–2.81)	0.68 (0.25–1.86)
Unemployed	61	73	1.35 (0.68–2.66)	0.75 (0.29–1.41)
Merchant/daily laborer	21	45	0.75 (0.34–1.65)	0.48 (0.17–1.38)
Government/private employed	18	29	1	1
Relationship status	Married	242	308	1	1
Unmarried	30	23	1.66 (0.94–2.93)	0.89 (0.45–1.77)
Nature/desire of pregnancy	Wanted	213	306	1	1
Unwanted	59	25	3.39 (2.06–5.59)*	1.94 (1.10–3.47)**
Acceptance of IPV	Yes	169	110	3.30 (2.36–4.61)*	2.39 (1.64–3.48)**
No	103	221	1	1
Age of partner (years)	20–29	72	117	1	1
≥ 30	200	214	1.52 (1.07–2.16)*	1.58 (0.84–2.98)
Educational status of partner	No formal education	191	199	1.82 (1.19–2.81)*	1.45 (0.69–3.02)
Primary education	41	56	1.39 (0.80–2.43)	1.43 (0.68–2.99)
Secondary and above	40	76	1	1
Occupational status of partner	Farmer	205	230	1.46 (0.89–2.38)	0.63 (0.27–1.48)
Unemployed	6	5	1.96 (0.55–6.99)	0.72 (0.17–3.13)
Merchant/daily laborer	31	47	1.08 (0.57–2.04)	0.43 (0.18–1.04)
Government/private employed	30	49	1	1
Cigarette smoking habit	Yes	115	72	2.64 (1.85–3.76)*	1.36 (0.86–2.15)
No	157	259	1	1
Khat chewing habit	Yes	189	143	2.99 (2.14–4.20)*	1.99 (1.31–3.03)**
No	83	118	1	1
Had multiple sexual partner	Yes	88	48	2.82 (1.90–4.20)*	1.63 (1.03–2.58)**
No	184	283	1	1
Number of family members	≤ 4	120	170	1	1
≥ 5	152	161	1.34 (0.97–1.85)	0.81 (0.49–1.35)
Extended family	Yes	33	29	1.44 (0.85–2.44)	1.253 (0.68–2.29)
No	239	302	1	1

Discussion

This study aimed to assess the prevalence of IPV and identify factors influencing its occurrence during pregnancy in the Argoba district, Ethiopia. The overall prevalence of IPV during the most recent pregnancy was determined to be 45.1% (95% CI: 41.1–49.1). This finding aligns with several studies conducted in Ethiopia, Uganda, South Africa, and Portugal, where IPV prevalence ranged from 41% to 48% [18, 19, 39–43].

However, this prevalence was lower than that reported in previous Ethiopian studies conducted in Gondar (58.7%) [16] and the Bale Zone (59%) [19]. The discrepancy in prevalence between this study and the Bale Zone study might be attributed to the broader classification of IPV used in Bale Zone, which included economic and controlling behavior violence, unlike the classification restricted to physical, sexual, and emotional violence in the current study. Additionally, variations in women's perceptions of violence by intimate partners could contribute to differences in prevalence.

Conversely, this study's findings were higher than those reported in earlier Ethiopian studies conducted in Harar (39.8%) [22] Wondogenet, Southern Ethiopia (21%) [20]. Jimma (35.6%) [37], and other countries such as Nigeria (33%) [44], Brazil (33%) [30], Japan (11.1%) [34], and India (31.6%) [45]. These discrepancies may stem from socio-cultural differences in the study populations and variations in study settings. The prevalent belief that men have the right to beat their wives, particularly common in Africa and South Asia, contrasts with attitudes in Central and Eastern Europe, Latin America, and the Caribbean. The deeply ingrained traditional belief in IPV in the study area may contribute to its high prevalence compared to studies in other countries.

The differences observed in prevalence might also be influenced by factors such as awareness levels and education. Unlike the present study, participants in Harar were predominantly urban dwellers, with higher levels of formal education among both respondents and their partners. Additionally, the timing and type of study setting could contribute to differences in prevalence. Unlike this community-based study, most studies in Ethiopia, Nigeria, Brazil, and Japan were facility-based and predominantly conducted in urban settings, potentially resulting in lower IPV prevalence. Variation in sampling methods and the inclusion of different types of IPV in assessments could also contribute to discrepancies in prevalence rates. For example, while this study included sexual violence, a study conducted in Japan focused only on psychological and physical IPV.

This study also investigated the prevalence of various types of IPV during pregnancy. The prevalence of psychological violence (38.0%) aligned closely with findings from Uganda (40%) [42], but was lower than observed rates in Gondar (57.8%) [16] and East Gojam, Ethiopia (44.2%) [29] and higher than several studies conducted in Ethiopia, South Africa, and Japan, where prevalence ranged from 10.8% to 33% [16–20, 34, 39]. Differences in women's awareness of violence in their respective communities could explain these disparities. Similarly, the prevalence of physical violence (24.7%) was comparable to rates found in Debre Markos (21%) [18] and Harar, Ethiopia (25.9%) [22]; but lower than in Gondar (32%) [16], Abay Chomen in Ethiopia (29%) [39], and South Africa (29%) [41], while higher than in Tigray (13.4%) [17], Bale (20.3%) [19], Wondogent Ethiopia (10%) [20], and Japan (1.2%) [34]. This variation may be attributed to differences in the presence of traditional norms supporting violence against pregnant women.

The prevalence of sexual violence (18.6%) in this study was consistent with findings from Debre (19.8%) [18], Tigray (17.7%.) [17], and South Africa (20%) [41], but lower than rates reported in East Gojam (42.9%) [29], Bale (36.3%) [19] and Abay Chomen (30%) [39], and Gondar (7.6%) [16], Harar (3.7%) [22], and Wondogent (10%) [20]. These variations could stem from differences in perceptions of violence and sexual autonomy within the studied populations. In terms of the hierarchy of IPV types, psychological violence emerged as the most prevalent, followed by physical and sexual violence, a trend supported by various studies in Ethiopia and beyond [16–20, 29, 41, 42]. This pattern may be attributed to the emotional impact experienced by women who endure physical and sexual violence.

Regarding factors associated with IPV during pregnancy, participants with unwanted pregnancies faced a twofold higher risk of experiencing IPV compared to those with wanted pregnancies, aligning with earlier studies in Ethiopia's Tigray, Bale, Wondogenet, and Eastern regions beyond [17, 19, 20, 27]. This heightened risk may stem from communication breakdowns between partners and strained relationships among women with unwanted pregnancies and their partners. Notably, unwanted pregnancies can lead to IPV or vice versa, as coerced sex may influence women's contraceptive choices. Additionally, the acceptance of IPV by women was significantly linked to its presence during pregnancy. Women who tolerated any form of IPV were over twice as likely to experience IPV compared to those who did not accept it, mirroring findings from previous studies in Gondar, Tigray, Harer, and Jimma, Ethiopia beyond [16, 17, 22, 37]. This acceptance could be attributed to entrenched traditional beliefs regarding gender roles and the normalization of IPV, where disobedience by women is often seen as grounds for punishment by their husbands.

This study also uncovered a significant association between partner khat chewing habits and IPV during pregnancy, with the likelihood of experiencing IPV doubling among participants whose partners engaged in this behavior. This finding is consistent with research in Bale, Eastern Ethiopia, and Brazil [19, 27, 30] suggesting that khat's stimulant properties may contribute to increased aggression and altered mental judgment, heightening the risk of violence in relationships. Furthermore, women whose partners had multiple wives or sexual partners had a nearly two times higher likelihood of experiencing IPV, echoing findings from studies in Tigray, Ethiopia [17]. This may be attributed to religious and cultural norms that permit polygamous relationships, potentially exacerbating violence against women with partners who engage in such behavior.

Strength and Limitation of the Study

Strengths of this study include its community-based approach, encompassing nonusers of ANC services who are often the most vulnerable to IPV, along with the utilization of female data collectors to engage with women holistically, thereby minimizing social desirability bias. However, limitations exist, including the potential for recall bias and social desirability bias due to the sensitive nature of the topic, though efforts were made to mitigate these biases by focusing solely on the most recent pregnancy and employing female data collectors. Additionally, the absence of qualitative methods and the exclusion of behavioral factors of women represent further limitations, highlighting areas for potential improvement in future investigations of IPV predictors.

Conclusions and Recommendations

In conclusion, the prevalence of IPV during pregnancy in this study was notably high, with nearly half of the women experiencing at least one form of IPV. This poses serious health risks for both the mother and fetus. Psychological violence emerged as the most prevalent form, followed by physical and sexual violence. Significant factors independently associated with IPV during pregnancy included unwanted pregnancy, acceptance of IPV by women, having a partner who chews khat, and spouses having multiple sexual partners.

Based on the findings of this study, the following recommendations are proposed. For policymakers and program planners, advocating for stronger laws against IPV, implementing empowerment programs for women, and addressing substance abuse, particularly khat chewing, are essential. For the Argoba district health office and NGOs working on MCH programs, implementing comprehensive sex education, conducting public awareness campaigns, engaging community leaders, and ensuring healthcare providers are trained to identify signs of IPV are crucial steps. Healthcare providers and HEWs should encourage couples to seek counseling, provide health education on IPV and substance abuse, while researchers are encouraged to conduct further qualitative and longitudinal studies on IPV during pregnancy and its associated factors.

Author Contributions

Destaw Asefa: conceptualization, writing–original draft, methodology, formal analysis, data curation, project administration, resources, software. Endalkachew Worku Mengesha: software, validation, writing–review and editing, supervision, formal analysis. Zemenu S. Yadita: validation, writing–review and editing, software, supervision, formal analysis. All authors have read and approved the final version of the manuscript.

Acknowledgments

We would like to thank Bahir Dar University, the Amhara Region Health Bureau, Amhara Public Health Institute, for their close support. We are grateful to study participants, supervisors, and data collectors for their willingness and cooperation during data collection and fieldwork. The authors received no specific funding for this work.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request. All data supporting the findings is submitted with the manuscript. The data set for this article is openly accessible without restriction. The corresponding author had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

Transparency Statement

The lead author Zemenu Shiferaw Yadita affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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