Justification of Wife Beating and Utilization of Antenatal and Delivery Care in Bangladesh

Abstract

We examined the association between women’s justification of wife beating and their utilization of professional antenatal and delivery care in Bangladesh. We used data which describes a nationally representative sample of currently married women aged 15 to 49 years (n = 3,449). Services from medically trained providers were considered professional antenatal care (ANC) and delivery services. Women’s attitudes toward wife beating in five circumstances (if a woman goes out without telling her husband, neglects children, argues with her husband, refuses to have sexual intercourse with her husband, and burns food) were used to describe the justification of wife beating. Chi-square tests and multilevel logistic regression analyses were performed; 74% of the women would not justify wife beating, 65% attended ≥1 ANC visits, 25% attended ≥4 ANC visits, and 44% utilized professional delivery care. Women who would not justify wife beating were more likely to utilize ≥1 ANC visits (adjusted odds ratio [AOR]: 1.89; 95% confidence interval [CI]: [1.26, 2.81]), ≥4 ANC visits (AOR: 1.14; 95% CI: [0.76, 1.71]), and professional delivery care (AOR: 1.93; 95% CI: [1.31, 2.85]). Older age, women’s and husband’s higher education, lower parity, urban residence (except for ≥1 ANC visits), and higher socioeconomic statuses including divisional differences were significant confounders for increased utilization of both professional ANC and delivery care. In addition, older age at marriage and current unemployment were also associated with increased utilization of delivery care services. This association between women’s justification of wife beating and their utilization of professional antenatal and delivery care services has potential implications for maternal and child health policy in Bangladesh where intimate partner violence is commonplace, and societal norms teach women to obey their husbands and accept submissive roles. Public policy should aim to create awareness among women about the negative impact of justifying wife beating, and accepting intimate partner violence on their own and children’s health.

Keywords

wife beating intimate partner violence antenatal care delivery care services Bangladesh

Introduction

Although maternal mortality worldwide dropped by about 44% between 1990 and 2015, approximately 830 women die every day from preventable causes related to pregnancy and childbirth, and 99% of all maternal deaths occur in developing countries (World Health Organization, 2015). In spite of pregnancy and childbirth being normal physiological phenomena, estimates show that globally 9% to 10% of pregnant women or 14 million women suffer from acute maternal complications during pregnancy every year (Filippi et al., 2006; Hogan et al., 2010). In Bangladesh, the maternal mortality ratio was 194 deaths per 100,000 live births in 2010 (El Arifeen et al., 2014), and in 2014, about 36% of women did not receive any antenatal care (ANC) visits, 31% of women received ≥4 ANC visits, and 42% deliveries were assisted by trained health care providers (National Institute of Population Research and Training [NIPORT] et al., 2016). Although every pregnant woman should utilize ≥4 ANC visits to have effective clinical outcomes and perceived satisfaction (Carroli et al., 2001), low utilization of ANC and delivery care occurred due to a number of barriers, for example, costs, transportation problems, and sociocultural norms to deliver at home (Parkhurst et al., 2006). Previous studies have recognized ANC and delivery care as effective in preventing maternal mortality and serious morbidity (Carroli et al., 2001; Graham et al., 2001; Koblinsky & Tinker, 1994; McDonagh, 1996). Therefore, increasing proper utilization of ANC and delivery care services are crucial for reducing maternal deaths from preventable causes related to pregnancy and childbirth in Bangladesh, and in turn, would help achieve Sustainable Development Goals related to maternal mortality reduction.

In various developing country settings, studies show that older maternal age, higher maternal education, higher husband’s education, higher socioeconomic status, lower parity, and urban residence are associated with increased utilization of ANC and delivery care services (Gabrysch & Campbell, 2009; Onah et al., 2006). Having an unwanted pregnancy (Rahman et al., 2016) and intimate partner violence (Rahman et al., 2012) were reported to be associated with under-utilization of ANC and delivery care services from medically trained providers in Bangladesh.

Female participation in economic, household, and health care decision making are considered as the indicators of female empowerment and autonomy in Bangladesh (M. Haque et al., 2011). Earlier studies have found a positive association between female autonomy and ANC utilization and suggested that under-utilization of ANC might be due to lack of female empowerment (Adamu & Salihu, 2002; S. E. Haque et al., 2012; Matsumura & Gubhaju, 2001; Mumtaz & Salway, 2005; Pallikadavath et al., 2004; Woldemicael, 2010). In 33 developing countries, maternal health services utilization were significantly associated with economic status, education, and female empowerment (Ahmed et al., 2010). A significant positive association between the utilization of ANC and female empowerment was also found in Bangladesh (Hossain & Hoque, 2015), where female empowerment was measured by education, household decision-making power, freedom of choice and movement, and involvement in economic activities.

While women are justifying wife beating less and less—from 33% in 2011 to 28% in 2014—Bangladeshi women often agree with one or more reasons of wife beating (e.g., if a woman goes out without telling her husband, neglects children, argues with her husband, refuses to have sexual intercourse with her husband, and burns food; NIPORT et al., 2013, 2016). In Bangladesh, women’s justification of wife beating is considered to be a proxy for their status within the household and indicative of a greater sense of entitlement, self-esteem, and status (NIPORT et al., 2016). A woman who justifies wife beatings may consider herself to have low status in her household, both absolutely and relative to the men in the household. Justifying wife beating also indicates a low level of female empowerment and an acceptance of men’s malpractice of power over women (Kishor & Subaiya, 2008). Such a perception could act as a barrier to a woman accessing health care for herself and her children, and affect her attitude toward contraceptive use and her general well-being. Our recent study revealed female participation in household decision-making to be significantly and negatively associated with the justification of wife beating in Bangladesh (Alam et al., 2018). Moreover, women who do not justify wife beating are more likely to participate in household decision-making, specifically with regard to their own health care and the health care of their children (Alam, 2016). These studies suggest a hypothesis that women who do not justify wife beating may more often seek ANC and delivery care services from medically trained providers.

However, existing research is inconclusive regarding the association between justification of wife beating and health care utilization, specifically ANC and delivery care. On one hand, justification of wife beating showed no association to overall health service, ANC, and delivery care utilization in Nepal (Pandey et al., 2012), and in Kenya, Nepal, and India (Namasivayam et al., 2012). However, evidence from Namibia has demonstrated an association of the justification of wife beating with institutional deliveries, but not with ANC from medically trained providers (Namasivayam et al., 2012). And in a few other contexts, such as Albania and Ethiopia, justification of wife beating was negatively associated with ANC and delivery care utilization (S. E. Haque et al., 2012; Sado et al., 2014; Yesuf & Calderon-Margalit, 2013).

The inconsistency of these results and the implications for maternal and child health policy indicate the need for more investigation of the association between the justification of wife beating and the utilization of ANC and delivery care. If women’s justification of wife beating is associated with less utilization of ANC and delivery care, the implication is that the benefits of interventions to increase female empowerment and reduce women’s justification of wife beating may extend to the women’s own health care and to their children’s health care. The importance of these relationships is particularly salient in Bangladesh where intimate partner violence is commonplace, and societal norms teach women to obey their husbands and accept submissive roles. Hence this study examined the association between women’s justification of wife beating and the utilization of ANC and delivery care services from medically trained providers.

Method

Data

We utilized data from the 2014 Bangladesh Demographic and Health Survey (BDHS), a nationally representative sample survey of demographic and health indicators of ever-married women aged 15 to 49 years residing in non-institutional dwelling units in Bangladesh. The 2014 BDHS was conducted under the authority of the NIPORT of the Ministry of Health and Family Welfare of Bangladesh. Based on a two-stage stratified sample of households, it selected 18,000 residential households. A total of 18,245 ever-married women of reproductive age (15–49 years) were identified in the selected households and 17,863 were interviewed by female interviewers, for a response rate of 98%. The surveys were conducted from June 28 to November 9, 2014. Additional details of sampling design, survey instrument, and data collection procedure can be found elsewhere (NIPORT et al., 2016).

The 2014 BDHS administered three questionnaires: a household questionnaire, a woman’s questionnaire, and a community questionnaire. The contents of the questionnaires are based on the MEASURE DHS Model Questionnaires and were developed in English, and then translated into and printed in Bangla for data collection (for more details, see https://dhsprogram.com/). The woman’s questionnaire was used to collect data on the respondent’s background characteristics, current employment status, reproductive history, family planning methods, antenatal, delivery, postnatal and newborn care, justification of wife beating, husband’s characteristics, and other information. To minimize recall bias, we restricted our sample to the currently married women of age 15 to 49 years who had at least one birth in last 3 years. A total of 13,369 women who did not give birth in last 3 years and 53 women who were not currently married were dropped. Therefore, 4,441 women remained for further analysis. A total of 951 women were asked about justification of wife beating in the presence of their children, husbands, other males, and females, and were excluded to comply with ethics. We further removed 41 observations due to missing values for all variables used in this study, which left 3,449 currently married women’s information as final sample. A few women had more than one birth in last 3 years. Utilization of ANC and delivery care for only last births were used in this study.

Outcome Variables

Three outcome variables, namely, utilization of ≥1 professional ANC, utilization of ≥4 professional ANC, and utilization of professional delivery care, were considered in the study. We define professional ANC and professional delivery care in the same way as defined in the BDHS survey (NIPORT et al., 2016). ANC services from a qualified doctor, nurse, midwife, paramedic, family welfare visitor, community skilled birth attendant, medical assistant, or sub-assistant community medical officer were considered as professional ANC. Delivery care services from a qualified doctor, nurse, midwife, paramedic, family welfare visitor, or community skilled birth attendant were considered as professional delivery care. Based on the frequency of ANC visits, two outcome variables were created: (a) women receiving at least one professional ANC versus no professional ANC and (b) women receiving four or more professional ANC versus less than four professional ANC. The third outcome, utilization of professional delivery care, was dichotomized as 1 if women received professional delivery care services and 0 otherwise.

Predictor Variable

Whether a woman would not justify wife beating was considered as the main predictor variable for this study. Specifically, the predictor variable of interest is whether a women would not justify wife beating in each of the following five circumstances: if she goes out without telling her husband, if she neglects the children, if she argues with her husband, if she refuses to have sexual intercourse with her husband, and if she burns the food. The internal consistency among the five variables (i.e., five circumstances) was .78 (Cronbach’s α = .78). The predictor variable of interest, indicating that the woman would not justify wife beating, is a binary variable equal to 1 if the woman thought that a beating would not be justifiable under any of the five circumstances. In contrast, the predictor variable of interest is equal to 0 if the woman thought that beating would be justified in any of the five circumstances.

Confounding Variables

We selected potential confounding factors based on extant literature and data availability. Individual characteristics included respondent’s current age (grouped as 15–19, 20–34, and 35+ years), age at first marriage (<18 years or ≥18 years), respondent’s and husband’s education (illiterate, primary education with less than or equal to 5 years of schooling, secondary education with 6–10 years of schooling, and higher education with 11 years of schooling and above), respondent’s current employment status (employed or unemployed), respondent’s religion (Muslim or non-Muslim), parity (grouped as 1–2, and 3+), and current contraceptive methods. Current employment status was defined by whether the respondent worked for and received cash earnings from any of the following 10 occupational categories during the 7 days preceding the survey: professional/ technical, business, factory worker/blue-collar service, semiskilled labor/service, unskilled labor, farmer/agricultural worker, poultry/cattle raising, home-based manufacturing, domestic servant, and other. Current contraceptive method was a categorical variable distinguishing those not currently using any contraceptive method from those using female methods and those using couple/male methods. Pills, IUD, injections, female sterilization, and implants/Norplant were considered female contraceptive methods, whereas periodic abstinence, withdrawal, lactational amenorrhea, condom, male sterilization, and others were considered couple/male contraceptive methods. Household characteristics included respondent’s place of residence (rural or urban), region, and socioeconomic status. Region was categorized according to seven administrative divisions of Bangladesh (Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur, and Sylhet). The socioeconomic status was measured from the wealth index constructed using household assets and grouped as “poor” (bottom 40%), “middle” (next 40%), and “rich” (top 20%) (Filmer & Pritchett, 2001; Tareque et al., 2014).

Ethics Approval and Consent to Participate

The DHS Program is authorized to distribute, at no cost, unrestricted survey data files for legitimate academic research (see more details at http://dhsprogram.com/). We obtained permission from the DHS Program to download and analyze the 2014 BDHS dataset for the current study. As the de-identified data for this study came from secondary sources, this study does not require ethical approval. Before each interview is conducted, an informed consent statement is read to the respondent, who may accept or decline to participate. The privacy and confidentiality of the respondents during data collection were maintained strictly to avoid further endangering respondents (https://dhsprogram.com/What-We-Do/Protecting-the-Privacy-of-DHS-Survey-Respondents.cfm). In addition, due to sensitive nature of the questions on justification of wife beating, we have utilized only those women’s information who were interviewed alone.

Statistical Analyses

After descriptive statistics of the study sample, chi-square tests were used to identify differences in the proportion of professional ANC and delivery care utilization by justification of wife beating and other individual and household characteristics. Then, we examined the association between justification of wife beating and professional ANC and delivery care utilization with multilevel logistic regression models. The 2014 BDHS used multistage stratified sampling technique that was based on nested sources of variability such as individuals who were nested in households and households that were nested in communities. We thus used multilevel logistic regression models with a random intercept at the household and the community levels to take into account sampling variability. Log-likelihood ratio tests indicated that multilevel logistic regression models with random effects were necessary compared with single-level logistic regression models without random effects (results not shown). Multilevel analysis produces more valid results when lower levels are nested within higher levels (Rabe-Hesketh & Skrondal, 2006; Twisk, 2006). All analyses were performed taking into account the probability sample design, unless specified. The svy commands were used in descriptive and bivariate analyses, and probability weights, proposed by Rabe-Hesketh and Skrondal (2006), were applied in multilevel logistic regression analysis. The entire analysis of the study was performed with Stata/MP version 13.0 (StataCorp, LP, College Station, Texas, USA).

We have fit six multilevel regression models, two models for each outcome. For each outcome, the first models (results not shown) established a bivariate association between each outcome and justification of wife beating without any adjustments for confounders. The final models examined the association between each outcome and justification of wife beating with adjustment for individual and household-level confounding variables.

Results

Basic characteristics (Table 1) showed most of the respondents were under 35 years (94%), and seven in 10 respondents were married before reaching 18 years of age. Comparatively, a lower percentage of women (13%) than husbands (24%) were illiterate. Only 23% of respondents were currently working, and 70% of respondents had given birth to 1 to 2 children. One in three women were not using any contraceptive methods. Around three fourths of the respondents lived in rural areas, and one third came from Dhaka division.

Table 1.

Basic Characteristic of the Study Participants (N = 3,449).

Characteristics	M	SD ^a
Age	24.5	5.8
Age at first marriage	16.3	2.9
	Number^a	Percentage
Age group
15–19	752	21.9
20–34	2,483	71.9
35+	214	6.1
Age at first marriage
<18	2,477	72.1
≥18	972	27.9
Education
Illiterate	430	13.2
Primary	995	28.8
Secondary	1,688	49.5
Higher	336	8.5
Current employment status
Unemployed	2,697	76.9
Employed	752	23.1
Religion
Muslim	3,157	91.3
Non-Muslim	292	8.7
Parity
1–2	2,449	70.2
3+	1,000	29.8
Current contraceptive methods
No	1,072	30.5
Female methods	1,897	55.0
Couple/male methods	480	14.5
Husband’s education
Illiterate	788	23.9
Primary	1,053	30.4
Secondary	1,129	33.0
Higher	479	12.7
Place of residence
Rural	2,345	73.0
Urban	1,104	27.0
Region
Barisal	416	5.8
Chittagong	618	20.5
Dhaka	627	36.4
Khulna	459	9.1
Rajshahi	426	10.1
Rangpur	441	10.0
Sylhet	462	8.1

Note. M = Mean.

Unweighted values.

About 74% of respondents would not justify wife beating under the circumstances investigated (Figure 1); 97% of women would not justify wife beating when the wife burns the food and 81% of women would not justify wife beating when the wife argues with her husband. About 65% of respondents received ≥1 professional ANC, 25% received ≥4 professional ANC, and 44% received professional delivery care services (Figure 2). Professional ANC visits and delivery assistances taken were comparatively lower among women aged 15 to 19 years than women aged 20 to 29 years. Although the differences in professional ANC and delivery care by age groups are not statistically significant, both ≥1 and ≥4 professional ANC were utilized in the highest percentage by women aged 35 to 39 years, while the highest rate of professional delivery care were utilized by women of age 20 to 24 years.

Table 2 showed the bivariate association between utilization of professional ANC and delivery care services and justification of wife beating and sociodemographic characteristics. A significant association between women utilizing professional ANC and delivery care and not justifying wife beating was found; women who would not justify wife beating under the circumstances investigated were found to utilize professional ANC and delivery care at a higher rate than women who would justify wife beating in at least one circumstance. The participants who were married at 18+ years, with higher education, currently not working, of parity 1 to 2, using couple/male methods, with higher educated husband, residing in urban areas, from higher socioeconomic statuses, and from Khulna division were found to utilize professional ANC and delivery care at a higher rate than their counterparts.

Table 2.

Descriptive Statistics of Women by Receiving Professional ANC Visits and Delivery Assistance.

Characteristics	≥1 Professional ANC		≥4 Professional ANC		Professional Delivery Care
Characteristics	Number^a	%	Number^a	%	Number^a	%
Justification of wife beating
Justified in at least one circumstance	516	52.8	188	18.3	307	31.9
Not justified under any circumstances	1,745	68.8	732	27.5	1,233	48.2
p		.00		.00		.00
Age group
15–19	495	64.4	171	21.5	330	41.7
20–34	1,630	64.6	694	26.0	1,119	45.0
35+	136	65.5	55	65.5	91	38.7
p		.97		.32		.32
Age at first marriage
<18	1,545	62.2	571	22.0	972	38.0
≥18	716	71.0	349	33.0	568	59.1
p		.02		.00		.00
Education
Illiterate	170	42.1	40	9.8	85	18.7
Primary	542	54.2	160	15.3	309	32.4
Secondary	1,243	72.2	514	29.3	868	50.7
Higher	306	91.1	206	57.4	278	82.2
p		.00		.00		.00
Current employment status
Unemployed	1,798	66.6	741	26.5	1,250	45.7
Employed	463	58.2	179	20.2	290	37.8
p		.0		.0		.0
Religion
Muslim	2,054	64.4	824	24.8	1,395	43.7
Non-Muslim	207	66.7	96	28.0	145	45.9
p		.68		.45		.70
Parity
1–2	1,727	69.3	763	29.1	1,250	50.8
3+	534	53.5	157	15.6	290	27.6
p		.00		.00		.00
Current contraceptive methods
No	689	64.1	269	23.1	439	38.8
Female methods	1,216	63.5	454	22.9	809	42.3
Couple/male methods	356	70.1	197	37.3	292	60.5
p		.15		.00		.00
Husband’s education
Illiterate	344	45.2	96	10.9	176	22.8
Primary	618	57.9	181	17.0	372	35.0
Secondary	867	75.0	377	30.8	619	54.1
Higher	432	90.5	266	56.0	373	78.4
p		.00		.00		.00
Place of residence
Rural	1,424	59.7	464	18.9	868	37.3
Urban	837	78.0	456	41.6	672	61.6
p		.00		.00		.00
Socioeconomic status
Poor	663	47.9	176	11.4	351	25.9
Middle	982	68.8	370	25.6	665	46.2
Rich	616	88.9	374	50.5	524	74.3
p		.00		.00		.00
Region
Barisal	244	56.2	85	19.3	154	36.9
Chittagong	407	64.9	147	21.5	261	41.9
Dhaka	443	66.1	186	26.5	314	47.4
Khulna	329	73.1	149	31.4	280	59.2
Rajshahi	286	64.1	121	24.8	202	41.8
Rangpur	299	64.9	147	30.3	184	38.6
Sylhet	253	54.0	85	18.3	145	30.2
p		.05		.03		.00

Note. ANC = antenatal care.

The p values are of chi-square tests.

Unweighted values.

A bivariate association between each outcome and justification of wife beating using multilevel logistic regression without any adjustments for confounders revealed that women who would not justify wife beating under the circumstances investigated had greater odds of utilizing professional ANC and delivery services relative to women who would justify wife beating. Women who would not justify wife beating under the circumstances investigated were 3.44 times more likely to utilize ≥1 professional ANC, 2.15 times more likely to utilize ≥4 professional ANC, and 3.29 times more likely to use professional delivery care. The greater odds for not justifying wife beating persisted in ≥1 professional ANC and delivery services after adjusting for confounders in final models (Table 3). Women who would not justify wife beating under the circumstances investigated were 1.89 times more likely to utilize ≥1 professional ANC services, and 1.93 times more likely to receive professional delivery care than women who would justify wife beating in at least one circumstance. Younger women utilized professional ANC and delivery services less than older women. Older age at marriage (for only delivery services), more education, lower parity, husbands with more education, and urban residence (except for ≥1 ANC visits) were associated with greater likelihood of utilizing professional ANC and delivery services. Currently employed women had lower odds of utilizing professional delivery care than currently unemployed women. Compared with women from Barisal division, women from Dhaka, Khulna, and Rangpur divisions utilized ≥1 professional ANC services at a higher rate, women from Khulna and Rangpur divisions utilized ≥4 professional ANC services in higher rate, and women from Khulna division utilized professional delivery care services at a higher rate.

Table 3.

Association Between Justification of Wife Beating and Receiving Professional ANC Visits and Delivery Assistance.

Characteristics	≥1 Professional ANC		≥4 Professional ANC	Professional Delivery Care
Characteristics	AOR^a [95% CI]	p	AOR^a [95% CI]	p	AOR^a [95% CI]	p
Justification of wife beating
Justified in at least one circumstance	1.00		1.00		1.00
Not justified under any circumstances	1.89 [1.26, 2.81]	.00	1.14 [0.76, 1.71]	.54	1.93 [1.31, 2.85]	.00
Individual level
Age group
15–19	0.39 [0.15, 1.01]	.05	0.34 [0.13, 0.87]	.03	0.47 [0.19, 1.16]	.10
20–34	0.40 [0.18, 0.91]	.03	0.59 [0.27, 1.31]	.20	0.44 [0.20, 0.97]	.04
35+	1.00		1.00		1.00
Age at first marriage
<18	1.00		1.00		1.00
≥18	1.01 [0.63, 1.64]	.96	0.81 [0.53, 1.24]	.33	1.82 [1.19, 2.78]	.01
Education
Illiterate	1.00		1.00		1.00
Primary	2.11 [1.16, 3.86]	.02	2.19 [1.05, 4.56]	.04	1.72 [0.97, 3.04]	.06
Secondary	4.23 [2.18, 8.22]	.00	3.67 [1.66, 8.11]	.00	2.89 [1.53, 5.45]	.00
Higher	7.02 [2.31, 21.31]	.00	6.99 [2.58, 18.95]	.00	7.57 [2.60, 22.01]	.00
Current employment status
Unemployed	1.00		1.00		1.00
Employed	0.71 [0.46, 1.09]	.12	0.81 [0.52, 1.27]	.37	0.60 [0.39, 0.91]	.02
Parity
1–2	1.6 [1.04, 2.46]	.03	2.10 [1.32, 3.35]	.00	2.52 [1.57, 4.05]	.00
3+	1.00		1.00		1.00
Current contraceptive methods
No	1.00		1.00		1.00
Female methods	0.98 [0.66, 1.45]	.91	0.76 [0.53, 1.09]	.14	1.12 [0.77, 1.62]	.55
Couple/male methods	0.77 [0.41, 1.43]	.41	1.17 [0.71, 1.93]	.54	1.60 [0.92, 2.77]	.10
Husband’s education
Illiterate	1.00		1.00		1.00
Primary	1.84 [1.16, 2.92]	.01	1.30 [0.74, 2.26]	.36	1.85 [1.14, 2.99]	.01
Secondary	3.85 [2.09, 7.12]	.00	2.76 [1.52, 5.01]	.00	3.64 [2.00, 6.63]	.00
Higher	9.59 [3.75, 24.53]	.00	6.30 [2.83, 14.03]	.00	8.98 [3.80, 21.19]	.00
Household level
Place of residence
Rural	1.00		1.00		1.00
Urban	1.47 [0.91, 2.36]	.12	3.26 [2.06, 5.17]	.00	2.26 [1.43, 3.58]	.00
Socioeconomic status
Poor	1.00		1.00		1.00
Middle	2.96 [1.87, 4.67]	.00	2.61 [1.63, 4.18]	.00	2.58 [1.64, 4.06]	.00
Rich	13.17 [5.58, 31.03]	.00	8.85 [4.34, 18.06]	.00	10.05 [4.91, 20.60]	.00
Region
Barisal	1.00		1.00		1.00
Chittagong	1.38 [0.66, 2.90]	.39	0.85 [0.42, 1.71]	.65	0.92 [0.46, 1.85]	.82
Dhaka	2.20 [1.07, 4.53]	.03	0.95 [0.48, 1.85]	.87	1.40 [0.67, 2.92]	.37
Khulna	2.80 [1.24, 6.32]	.01	2.27 [1.09, 4.73]	.03	5.74 [2.42, 13.62]	.00
Rajshahi	2.15 [0.97, 4.74]	.06	1.75 [0.82, 3.73]	.15	1.94 [0.91, 4.12]	.08
Rangpur	2.82 [1.21, 6.58]	.02	4.55 [1.99, 10.43]	.00	1.62 [0.78, 3.39]	.20
Sylhet	1.08 [0.50, 2.35]	.84	1.01 [0.46, 2.25]	.98	0.64 [0.28, 1.45]	.29
Variance (cov) of random effect
Level 2 (household)	7.72 (2.36)		6.33 (1.77)		7.57 (2.16)
Level 3 (community)	1.49 (0.48)		1.35 (0.41)		1.26 (0.40)

Note. ANC = antenatal care; AOR = adjusted odds ratio; CI = confidence interval.

Adjusted for all variables in the table.

Discussion

The current study revealed important findings regarding women’s justification of wife beating and professional health care utilization. Women who would not justify wife beating under the five circumstances investigated utilized ≥1 professional ANC and delivery care services at significantly higher rates than women who would justify wife beating in at least one circumstance. Our findings indicated that women’s justification of wife beating needs to be considered as an important sociocultural determinant for sufficient utilization of professional maternal health services during and after pregnancy. We also identified some significant confounding factors influencing professional ANC and delivery care services, for example, women’s age, age at first marriage (for only delivery services), women’s and husband’s educational levels, women’s current employment status (for only delivery services), parity, place of residence (except for ≥1 professional ANC), and socioeconomic status including divisional differences.

The positive association between women not justifying wife beating under the circumstances investigated and their utilization of ≥1 professional ANC and delivery services utilization implies that interventions aimed at increasing the percentage of women who do not justify wife beating would significantly increase utilization of maternal health services. The association between women not justifying wife beating and the utilization of ≥4 professional ANC was not statistically significant and warrants further investigation because the utilization of ≥4 ANC visits is associated with better maternal health outcomes.

Increased utilization of professional ANC and professional delivery care services would help reduce maternal and child deaths and violence against women. Reductions to maternal and child deaths, and reduced violence against women are critical to the United Nations Sustainable Development Goals. Further research is merited to explore additional factors associated with the justification of wife beating. In addition, given how ingrained these attitudes toward wife beating are in Bangladeshi culture, future research testing and evaluating different interventions aimed at reducing women’s justification of wife beating is necessary. Given the negative association between women’s justification of wife beating and household decision-making, policy makers and planners should consider interventions designed to empower and educate women and increase their participation in household decision-making (Alam, 2016; Alam et al., 2018). However, policy makers and planners should also consider that many women may not disclose incidence of domestic violence because of fear for further bad treatment or because of shame or embarrassment (NIPORT et al., 2009).

In terms of confounding factors, our results align with previous research suggesting that older women were more likely to utilize professional ANC and delivery care services more than younger women (Gabrysch & Campbell, 2009; Rahman et al., 2016). Younger women may feel shy to visit professional ANC and delivery care services providers than older women. As women grow older, their roles as mothers become more prominent than as wives, as they achieve a certain status at the household and community (Kishor & Johnson, 2004) which may increase the utilization of professional ANC and delivery care services. The legal age at marriage for female is 18+ years in Bangladesh. However, many marriages are arranged for girls in their teens in Bangladesh (Johnston & Naved, 2008). Numerous studies reported disadvantages for women who got married young (Islam et al., 2014, 2015; Jejeebhoy, 1998; Jensen & Thornton, 2003; Rahman et al., 2016). For instances, women who were married young tend to participate less in household decision-making, are more likely to experience domestic violence, and are less likely to utilize professional ANC and delivery care services. The current study also revealed that women who got married at 18+ years were more likely to utilize professional delivery care services than women who got married at <18 years. Therefore, implementation of the existing law (i.e., marriage is legal at 18+ years for girls) may also increase utilization of professional delivery care services for prospective healthy mothers and children in Bangladesh.

Similar to our results, respondent’s education, husbands’ education, place of residence, and socioeconomic status were also strong confounders of professional ANC and delivery care utilization in a number of studies (Anwar et al., 2015; Furuta & Salway, 2006; Raghupathy, 1996; Rahman et al., 2016). More educated women and their husbands may have greater awareness of the benefits of professional ANC and delivery services than illiterate women and husbands. They may earn more and have higher socioeconomic status. Women from urban and higher socioeconomic groups may have the opportunity to spend more on professional ANC and delivery services than their counterparts. In addition, professional ANC and delivery care services are more available in urban areas than in rural areas. This suggests that policy makers should consider ways to increase the access to professional ANC and delivery care services in rural areas and among lower socioeconomic groups.

We also found that currently employed women were significantly less likely to use professional delivery care services than their counterparts, a result which differs from previous evidence from other developing settings which suggests that employed women have better knowledge of ANC services (El-Sherbini et al., 1992). Additional analysis from the dataset we used (results not shown) revealed that the mean year of schooling for currently employed women was lower than for currently unemployed women. This difference in education levels is a plausible explanation for why currently employed women utilized professional delivery care services at a lower rate than currently unemployed women in Bangladesh.

Although Bangladeshi women with more children experienced less intimate partner violence (Islam et al., 2014, 2015), they justify wife beating at similar rate compared with women with fewer children (Alam et al., 2018). Similar to the findings of a study (Rahman et al., 2016), we also found that women with fewer children utilized professional ANC and delivery care services at a higher rate than women with more children ever born. Having fewer children ever born would neither reduce nor increase justification of wife beating among women, but may be beneficial to increasing professional ANC and delivery care services utilization in Bangladesh.

Similar to other studies (Rahman et al., 2016) which document regional differences in utilization of professional ANC and delivery services, we found significant differences in utilization rates across regional divisions in Bangladesh. Compared with women from Barisal division, women from Dhaka, Khulna, and Rangpur divisions had higher odds of utilizing ≥1 professional ANC; women from Khulna and Rangpur divisions for ≥4 professional ANC; and Khulna division for professional delivery care service. These should be considered by the policy makers at the time of formulating ANC and delivery services–related policies.

Weaknesses and Strengths

This study has some limitations which should be considered when interpreting our findings. First, data were cross-sectional, and the study was unable to provide cause–effect relationships. Second, information of currently married women who gave at least one birth in last 3 years preceding the survey were used for this study, so the prevalence should not be generalized to women of all ages in Bangladesh. This study has several strengths as well. It used large population–based sample data with national coverage. It used multilevel analysis and incorporated probability weights in all analyses.

Implications

This study provides important findings on the association between women’s justification of wife beating and their utilization of professional ANC and delivery services. These associations imply that reducing women’s justification of wife beating will reduce intimate partner violence against women, and will improve maternal and child health through higher utilization of professional ANC and delivery care. Increasing the utilization of professional ANC and delivery care will help reduce maternal and child deaths, each being critical components of the Sustainable Development Agenda. The results indicate that policy makers should explore interventions aimed at creating awareness among women of the negative impact to their health and their children’s health of justifying wife beating under any circumstances. Although Bangladesh has made remarkable progress toward gender equality in every sector—particularly in school enrollment at the primary and secondary levels—gender norms are intimately bound up with religious beliefs and cultural practices. Many women may not disclose incidence of intimate partner violence because they believe in superiority of their husbands or fear further violence or because of embarrassment or shame (NIPORT et al., 2009). However, evidence suggests that empowering women through education, economic independence, and increasing women’s status in the household and in society may help women not to justify wife beating under any circumstances (Alam et al., 2018; Gupta et al., 2013; Kim et al., 2007). Policy makers and planners are also suggested to consider the current study’s findings on age at first marriage, women’s and husband’s education, women’s current employment status, parity, place of residence, and socioeconomic status including divisional differences when they formulate professional ANC and delivery care services–related policies and programs.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Md. Ismail Tareque

Md. Mosfequr Rahman

Author Biographies

Md. Ismail Tareque, PhD, is a professor at the Department of Population Science and Human Resource Development, University of Rajshahi (RU), Bangladesh. He is one of the founding member of National Young Academy of Bangladesh. His areas of research cover health expectancy, disability, population aging, intimate partner violence, and public health. In 2017, he was the youngest faculty to receive RU’s prestigious award, the “Dean’s Award” for his research work.

Md. Shahin Alam, MSc, was a research fellow at the Department of Population Science and Human Resource Development, RU, Bangladesh, during the preparation of this article. Now he is an officer at Janata Bank Limited, Bangladesh. His research interests include women’s empowerment, intimate partner violence, and public health.

Evan D. Peet, PhD, is an economist at the RAND Corporation and professor at the Pardee RAND Graduate School. His research focuses on factors driving the development of human capital and spans the areas of economic development, health, and labor economics. He is an applied microeconomist experienced with a broad array of econometric and machine learning tools for predictive and causal analysis. He received his PhD in economics from Duke University in 2013, then completed a postdoctoral fellowship in global and environmental health at Harvard University before joining the RAND Corporation in 2015.

Md. Mosfequr Rahman, PhD, is a professor of Population Science and Human Resource Development, RU, Bangladesh. His work encompassing intimate partner violence, women autonomy, unintended pregnancy, and maternal and child health have been published in top-tier journals and have been cited by researchers across the globe. He has attended and presented several of his works in national and international conferences in home and abroad. He has been awarded several scholarships and awards for his outstanding research, teaching, and services.

K. M. Mustafizur Rahman, MSc, MPhil, is a lecturer at the Department of Population Science, Jatiya Kabi Kazi Nazrul Islam University, Bangladesh. His research interests include women’s empowerment, intimate partner violence, poverty, inequality, and population aging.

References

Adamu

Salihu

(2002). Barriers to the use of antenatal and obstetric care services in rural Kano, Nigeria. Journal of Obstetrics and Gynaecology, 22(6), 600–603.

Ahmed

Creanga

A. A.

Gillespie

D. G.

Tsui

A. O.

(2010). Economic status, education and empowerment: Implications for maternal health service utilization in developing countries. PLOS ONE, 5(6), Article e11190.

Alam

M. S.

(2016). Participation in household decision making, unacceptance of wife beating and utilization of antenatal and delivery care among women in Bangladesh [Master’s thesis, Department of Population Science and Human Resource Development, University of Rajshahi].

Alam

M. S.

Tareque

M. I.

Peet

E. D.

Rahman

M. M.

Mahmud

(2018). Female participation in household decision-making and the justification of wife beating in Bangladesh. Journal of Interpersonal Violence, 0886260518772111. https://doi.org/10.1177/0886260518772111

Anwar

Nababan

H. Y.

Mostari

Rahman

Khan

J. A. M.

(2015). Trends and inequities in use of maternal health care services in Bangladesh, 1991-2011. PLOS ONE, 10(3), Article e0120309. https://doi.org/10.1371/journal.pone.0120309

Carroli

Rooney

Villar

(2001). How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatric and Perinatal Epidemiology, 15(Suppl. 1), 1–42.

Carroli

Villar

Piaggio

Khan-Neelofur

Gülmezoglu

Mugford

, . . . WHO Antenatal Care Trial Research Group. (2001). WHO systematic review of randomised controlled trials of routine antenatal care. The Lancet, 357(9268), 1565–1570.

El Arifeen

Hill

Ahsan

K. Z.

Jamil

Nahar

Streatfield

P. K

. (2014). Maternal mortality in Bangladesh: A countdown to 2015 country case study. The Lancet, 384(9951), 1366–1374.

El-Sherbini

El-Torky

Ashmawy

Abdel-Hamid

(1992). Assessment of knowledge, attitudes and practices of expectant mothers in relation to antenatal care in Assiut governorate. The Journal of the Egyptian Public Health Association, 68(5–6), 539–565.

10.

Filippi

Ronsmans

Campbell

O. M.

Graham

W. J.

Mills

Borghi

… Osrin

(2006). Maternal health in poor countries: The broader context and a call for action. The Lancet, 368(9546), 1535–1541.

11.

Filmer

Pritchett

L. H.

(2001). Estimating wealth effects without expenditure data—Or tears: An application to educational enrollments in states of India. Demography, 38(1), 115–132. https://doi.org/10.1353/dem.2001.0003

12.

Furuta

Salway

(2006). Women’s position within the household as a determinant of maternal health care use in Nepal. International Family Planning Perspectives, 32(1), 17–27.

13.

Gabrysch

Campbell

O. M.

(2009). Still too far to walk: Literature review of the determinants of delivery service use. BMC Pregnancy and Childbirth, 9, Article 34. https://doi.org/10.1186/1471-2393-9-34

14.

Graham

W. J.

Bell

J. S.

Bullough

C. H. W.

(2001). Can skilled attendance at delivery reduce maternal mortality in developing countries? In: Safe Motherhood Strategies: A Review of the Evidence (eds. De Brouwere

Van Lerberghe

). Studies in Health Services Organisation and Policy, 17, 97–130.

15.

Gupta

Falb

K. L.

Lehmann

Kpebo

Xuan

Hossain

… Annan

(2013). Gender norms and economic empowerment intervention to reduce intimate partner violence against women in rural Côte d’Ivoire: A randomized controlled pilot study. BMC International Health and Human Rights, 13(1), Article 46.

16.

Haque

Islam

T. M.

Tareque

M. I.

Mostofa

M. G.

(2011). Women empowerment or autonomy: A comparative view in Bangladesh context. Bangladesh e-Journal of Sociology, 8(2), 17–30.

17.

Haque

S. E.

Rahman

Mostofa

M. G.

Zahan

M. S.

(2012). Reproductive health care utilization among young mothers in Bangladesh: Does autonomy matter? Women’s Health Issues, 22(2), e171–e180.

18.

Hogan

M. C.

Foreman

K. J.

Naghavi

Ahn

S. Y.

Wang

Makela

S. M.

… Murray

C. J.

(2010). Maternal mortality for 181 countries, 1980–2008: A systematic analysis of progress towards Millennium Development Goal 5. The Lancet, 375(9726), 1609–1623.

19.

Hossain

Hoque

A. A.

(2015). Women empowerment and antenatal care utilization in Bangladesh. The Journal of Developing Areas, 49(2), 109–124.

20.

Islam

T. M.

Tareque

M. I.

Sugawa

Kawahara

(2015). Correlates of intimate partner violence against women in Bangladesh. Journal of Family Violence, 30(4), 433–444.

21.

Islam

T. M.

Tareque

M. I.

Tiedt

A. D.

Hoque

(2014). The intergenerational transmission of intimate partner violence in Bangladesh. Global Health Action, 7, Article 23591. https://doi.org/10.3402/gha.v7.23591

22.

Jejeebhoy

S. J.

(1998). Wife-beating in rural India: A husband’s right? Evidence from survey data. Economic and Political Weekly, 33(15), 855–862.

23.

Jensen

Thornton

(2003). Early female marriage in the developing world. Gender & Development, 11(2), 9–19.

24.

Johnston

H. B.

Naved

R. T.

(2008). Spousal violence in Bangladesh: A call for a public-health response. Journal of Health, Population and Nutrition, 26(3), 366–377.

25.

Kim

J. C.

Watts

C. H.

Hargreaves

J. R.

Ndhlovu

L. X.

Phetla

Morison

L. A.

… Pronyk

(2007). Understanding the impact of a microfinance-based intervention on women’s empowerment and the reduction of intimate partner violence in South Africa. American Journal of Public Health, 97(10), 1794–1802.

26.

Kishor

Johnson

(2004). Profiling domestic violence: A multi-country study. ORC Macro.

27.

Kishor

Subaiya

(2008). Understanding women’s empowerment: A comparative analysis of demographic and health surveys (DHS) data (DHS Comparative Reports No. 20). Macro International.

28.

Koblinsky

Tinker

(1994). Programming for safe motherhood: A guide to action. Health Policy and Planning, 9(3), 252–266.

29.

Matsumura

Gubhaju

(2001). Women’s status, household structure and the utilization of maternal health services in Nepal: Even primary-level education can significantly increase the chances of a woman using maternal health care from a modem health facility. Asia-Pacific Population Journal, 16(1), 23–44.

30.

McDonagh

(1996). Is antenatal care effective in reducing maternal morbidity and mortality? Health Policy and Planning, 11(1), 1–15.

31.

Mumtaz

Salway

(2005). “I never go anywhere”: Extricating the links between women’s mobility and uptake of reproductive health services in Pakistan. Social Science & Medicine, 60(8), 1751–1765.

32.

Namasivayam

Osuorah

D. C.

Syed

Antai

(2012). The role of gender inequities in women’s access to reproductive health care: A population-level study of Namibia, Kenya, Nepal, and India. International Journal of Women’s Health, 4, 351–364.

33.

National Institute of Population Research and Training (NIPORT), Mitra and Associates, & Macro International. (2009). Bangladesh demographic and health survey 2007.

34.

National Institute of Population Research and Training (NIPORT), Mitra and Associates, & ICF International. (2013). Bangladesh demographic and health survey 2011.

35.

National Institute of Population Research and Training (NIPORT), Mitra and Associates, & ICF International. (2016). Bangladesh demographic and health survey 2014.

36.

Onah

H. E.

Ikeako

L. C.

Iloabachie

G. C.

(2006). Factors associated with the use of maternity services in Enugu, southeastern Nigeria. Social Science & Medicine, 63(7), 1870–1878.

37.

Pallikadavath

Foss

Stones

R. W.

(2004). Antenatal care: Provision and inequality in rural north India. Social Science & Medicine, 59(6), 1147–1158.

38.

Pandey

Lama

Lee

(2012). Effect of women’s empowerment on their utilization of health services: A case of Nepal. International Social Work, 55(4), 554–573.

39.

Parkhurst

J. O.

Rahman

S. A.

Ssengooba

(2006). Overcoming access barriers for facility-based delivery in low-income settings: Insights from Bangladesh and Uganda. Journal of Health, Population and Nutrition, 24(4), 438–445.

40.

Rabe-Hesketh

Skrondal

(2006). Multilevel modelling of complex survey data. Journal of the Royal Statistical Society: Series A (Statistics in Society), 169(4), 805–827. https://doi.org/10.1111/j.1467-985X.2006.00426.x

41.

Raghupathy

(1996). Education and the use of maternal health care in Thailand. Social Science & Medicine, 43(4), 459–471.

42.

Rahman

M. M.

Nakamura

Seino

Kizuki

(2012). Intimate partner violence and use of reproductive health services among married women: Evidence from a national Bangladeshi sample. BMC Public Health, 12, Article 913.

43.

Rahman

M. M.

Rahman

M. M.

Tareque

M. I.

Ferdos

Jesmin

S. S.

(2016). Maternal pregnancy intention and professional antenatal care utilization in Bangladesh: A nationwide population-based survey. PLOS ONE, 11(6), Article e0157760. https://doi.org/10.1371/journal.pone.0157760

44.

Sado

Spaho

Hotchkiss

D. R.

(2014). The influence of women’s empowerment on maternal health care utilization: Evidence from Albania. Social Science & Medicine, 114, 169–177.

45.

Tareque

M. I.

Begum

Saito

(2014). Inequality in disability in Bangladesh. PLOS ONE, 9(7), Article e103681. https://doi.org/10.1371/journal.pone.0103681

46.

Twisk

J. W.

(2006). Applied multilevel analysis: A practical guide for medical researchers. Cambridge University Press.

47.

Woldemicael

(2010). Do women with higher autonomy seek more maternal health care? Evidence from Eritrea and Ethiopia. Health Care for Women International, 31(7), 599–620.

48.

World Health Organization. (2015). Maternal mortality. http://www.who.int/mediacentre/factsheets/fs348/en/

49.

Yesuf

E. A.

Calderon-Margalit

(2013). Disparities in the use of antenatal care service in Ethiopia over a period of fifteen years. BMC Pregnancy and Childbirth, 13(1), Article 131.