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International Journal of Population Studies
International Journal of Population Studies | 2016, Volume 2, Issue 2 107
RESEARCH ARTICLE
Utilization of maternal and child health care
services in North and South India: does spousal
violence matter?
Atreyee Sinha1* and Aparajita Chattopadhyay2
1 International Institute for Population Sciences (IIPS), Govandi Station Road, Deonar, Mumbai- 400088,
Maharashtra, India
2 Department of Development Studies, International Institute for Population Sciences (IIPS), Govandi
Station Road, Deonar, Mumbai- 400088, Maharashtra, India
Abstract: Spousal violence emerged as a major public health concern over the past few decades as
its consequences on the health of victims are profound. Infliction of violence during pregnancy is even
more detrimental as it might cause serious injuries to women and their unborn children. Violence during
pregnancy can restrict access to proper health care and affect the health of mother and child. However, the
role of spousal violence on utilization of pregnancy care services is not well explored in India where both
fertility and spousal violence are high. In the present study, we used data of selected North and South In-
dian states from the National Family Health Survey (2005–2006) to examine the relationship between
experience of spousal violence by young married women and utilization of maternal and child health care
services. A marked regional variation was observed in MCH care utilization and levels of violence, where
the South Indian states performed better than the North. Spousal violence was a significant factor deter-
mining MCH care use. Women who had experienced any form of physical/sexual violence were less
likely to receive full ante natal care than non-abused women and the association was stronger in the South.
Women experiencing any physical/sexual violence were also less likely to avail institutional delivery in
the North. Emotional violence had similar constraining effects on MCH care use in the South. Integration
of violence screening and counselling with MCH programs could be helpful to address the needs of
abused pregnant women and provide essential care.
Keywords: spousal violence, maternal and child health care services, ante natal care, institutional deli-
very, India
*Correspondence to: Atreyee Sinha, International Institute for Population Sciences (IIPS), Govandi Station Road, Deonar,
Mumbai-400088, Maharashtra, India; Email: atreyee_dabloo@yahoo.com
Received: September 15, 2015; Accepted: October 30, 2016; Published Online: December 21, 2016
Citation: Sinha A and Chattopadhyay A. (2016). Utilization of maternal and child health care services in North and
South India: Does spousal violence matter? International Journal of Population Studies, vol.2(2): 107–122.
http://dx.doi.org/10.18063/IJPS.2016.02.001.
1. Introduction
Quality care during pregnancy and child birth is essential to ensure health and well-being of both the
mother and the child. A majority of the maternal deaths associated with pregnancy complications
and child birth result from lack of access to and receipt of routine health care and emergency
health care services (Fawole, Shah, Fabanwo et al., 2012; Ibeh, 2008) and this is particularly so in
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Atreyee
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Utilization of maternal and child health care services in North and South India: does spousal violence matter?
108 International Journal of Population Studies | 2016, Volume 2, Issue 2
sub-Saharan and south Asian countries (UNICEF, 2008; WHO, 2014). For the sake of maternal
and child welfare, it is pertinent to understand the role of women’s educational attainment, employ-
ment status, economic status, geographic accessibility to and availability of health care services and
women’s ability to decide how to spend their own earnings for self health care (Mohanty and Pathak,
2009; Navaneetham and Dharmalingam, 2002; Ram and Singh, 2006; Furuta and Salway, 2006;
Olufunmilayo and Adeoye, 2015). Women’s education, mobility, access to economic resources, sta-
tus in the household, decision making authority, economic condition of the family, and geographic
region are some important determinants of maternal health care utilization (Furuta and Salway, 2006;
Singh, Rai and Singh, 2012). In societies that are driven by men, husband’s supportive stance is al-
so considered to be an essential component in increasing utilization of maternal and child care ser-
vices (Chattopadhyay, 2011). It is argued that poor communication between couples and gender in-
equality constraint women’s access to health care services. In this regard, spousal violence can be
seen as a manifestation of unequal power relations between men and women in a marriage.
Spousal violence is any abuse or violent action that occurs between two individuals in a close re-
lationship like marriage and has many forms including physical aggression or assault, sexual and
emotional abuse, controlling or domineering (WHO, 2012). Although the term spousal violence in-
volves both men and women, with either sex as the perpetrator, the majority of abuses are perpe-
trated by men against their female partners (Krug, Dalhberg, Mercy et al., 2002). Societies with a
strong patrilineal-patrilocal-patriarchal foundation deny equality between men and women. Biased
gender role attitudes prevailing in the traditional patriarchal societies force women to be domesti-
cated and build perceptions of social roles that confine women to the four walls of a household
dwelling, with activities centred on bearing and rearing of children and caring for the family. In such
environments, women who are at the receiving end of physical, sexual and emotional abuse, learn to
accept it as the “husband’s right” (Visaria, 2000).
Spousal violence has emerged as an important public health concern in both developed and de-
veloping nations, mainly in African and Asian countries including India, as it leads to poor physical,
reproductive and mental health outcomes for women and has far reaching consequences on children
as well (Campbell, 2002; Ellsberg, Jensen, Heise et al., 2008; Silverman, Decker, Gupta et al., 2009).
Intimate partners who are physically violent may interfere with the receipt of healthcare services by
their female counterparts (McCloskey, Williams, Lichter et al., 2007). Existing literature in South
Asia and Africa suggests that presence of violence in a household may reduce the utilization of ma-
ternal and child health care services resulting in poor health status of both the mother and the child
(Monemi, Pena, Ellsberg et al., 2003). Studies in Bangladesh and Nigeria found that intimate partner
violence plays a significant role in lowering the utilization of reproductive health services among
women and concluded that in addition to a wide range of socio-demographic factors, preventing
physical and sexual violence needs to be considered as an important psychosocial determinant to
increase utilization of reproductive health care services (Ononokpono and Azfredrick, 2014; Rahman,
Nakamura, Seino et al., 2012). Using the Women's Reproductive Histories Survey (WRHS) in 2002
a study reveals that in India, among nuclear families, women with better marital relationships are
more likely than their counterparts to use antenatal care services and deliver in a health-care facility
(Allendorf, 2010).
Violence during pregnancy could be associated with negative pregnancy outcomes through
its constraining effects on women's use of preventative or curative health services (Koski, Stephen-
son and Koenig, 2011). It was observed that women who experienced physical violence during
pregnancy were less likely to receive prenatal care, a home-visit by a health worker for a prenat-
al check-up, at least three prenatal care visits, and less likely to initiate prenatal care early in the
pregnancy (Koski, Stephenson and Koeing, 2011). The goal of prenatal and ante natal care services
is to maximize the health outcomes of both the mother and the child. Proper care of the mother and
education given to the mother during pregnancy are extremely important to ensure positive effects
on maternal health as well as pregnancy outcomes. Therefore, a lack of prenatal care correlates to
Atreyee Sinha and Aparajita Chattopadhyay
International Journal of Population Studies | 2016, Volume 2, Issue 2 109
increased risks of premature births, low birth weight, neonatal and infant mortality, and maternal
mortality (Hossain and Hoque, 2005; Nigussie Mariam and Mitike, 2004).
In India, 35% ever married Indian women aged 15–49 years reported to have experienced domes-
tic violence in various forms in the hands of their intimate partners (IIPS and Macro International,
2007) and this depicts the poor condition of women even within families. The presence of violence
within intimate relationships like marriage, leaves women in extremely powerless condition, lacking
the ability to take decisions. This may in turn reduce proper utilization of health care services by
them. Therefore, studying the association of spousal violence and health care utilization calls for
special attention. The present paper aims to examine how the level of maternal and child health
(MCH) care utilization differs in North and South Indian states by experience of spousal violence
and to what extent the experience of spousal violence plays a role in determining the utilization of
full ANC and institutional delivery for young married women.
The rationale behind looking into North and South India separately is the prevailing cultural and
social heterogeneity. Cultural norms and behaviours in India are diverse; extent of patriarchy is also
varied and is directed by regionally prescribed social systems. The Southern part of the country al-
lows women to have more exposure to the outside world, more voice in family life, and more free-
dom of movement than that of the North (Jejeebhoy, 2000; Jejeebhoy and Sathar, 2001). These pre-
vailing societal norms and beliefs account for low status and esteem of women within the family, in
the society and even to the self. This stratified gender relations in the Northern society has come out
to be more narrow in acknowledging women’s values and their decision making power, constraining
their every move and access to resources and conferring them the status of a mere product in the tra-
ditional dowry market (Dyson and Moore, 1983; Jejeebhoy and Sathar, 2001; Jejeebhoy, 2002). The
ideology of male supremacy legitimises the use of force as the vehicle to display the male power
over them (Jewkes, 2002) and the violent turn up of an intimate relation, as mentioned by many au-
thors, is an extension of the belief that men have an eternal right to control women’s behaviour (Vi-
saria, 2008; Campbell, Webster, Koziol-Mclain et al., 2003; Monemi, Pena, Ellsberg et al., 2003;
Parish, Wang, Lauman et al., 2004).
In addition to the cultural differences, the well documented North-South divide also exists on
various development indices and this has been prevailing in the country consistently over a long pe-
riod of time (Dyson and Moore, 1983). It is argued that there exists a considerable gender disparity
in terms of life expectancy at birth, various health outcomes like maternal and child mortality, fe-
male literacy and female work participation where South Indian states perform better; this in turn
depicts a distinct regional imbalance in terms of women’s position in the family and their vulnerabil-
ity (Dyson and Moore, 1983). Powerlessness among women is more acute in North India (Karve,
1965). Women in the North have relatively lower autonomy, freedom of movement, exposure to the
outside world, control over material and economic resources, and property inheritance rights than the
women in the South especially after marriage (Jejeebhoy and Sathar, 2001). As gender equity
is closely associated with the use of health care services, it is assumed that, in the North Indian states,
the level of maternal and child health care utilization will be lower and the effect of spousal violence
on MCH care utilization will be stronger in comparison to the South Indian states.
2. Data and Methods
2.1 Study Sample
We used data from the third round of Indian Demographic Health Survey (DHS) known as National
Family Health Survey — NFHS-3, 2005–2006. A sample of currently married women, aged 15–30
years from few Indian states, selected on the basis of high incidence of spousal violence, was consi-
dered for analysis. The first group of selected states were Bihar, Madhya Pradesh, Rajasthan, and
Uttar Pradesh with 60.8%, 49.1%, 50.2%, and 45.0% ever married women experiencing spousal vi-
Utilization of maternal and child health care services in North and South India: does spousal violence matter?
110 International Journal of Population Studies | 2016, Volume 2, Issue 2
olence respectively. These four states were combined as North Indian states and were referred as the
North states henceforth. The second group of states consisted of Maharashtra, Andhra Pradesh, and
Tamil Nadu with the level of spousal violence at 33.4%, 36.8%, and 44.1% respectively. These three
states were grouped as South Indian states and were referred as the South states (IIPS and Macro
International, 2007). The selection of states was based on the higher incidence of spousal violence in
order to avoid the variations in the prevalence of spousal violence and to compare its effects on the
utilization of MCH care services.
The sample for this study was young married women, aged 15–30 years, with at least one
live birth in the five years prior to the survey. The sample size was 4,837 for the North and 3,304 for
the South. According to national survey (IIPS and Macro International, 2007) a majority of the ever
married women interviewed for domestic violence schedule, reported that the perpetrator of physical
violence were their husband and also spousal violence was mostly experienced by women at lower
ages, i.e., below 30 years (IIPS and Macro International, 2007). Therefore, we restricted the sample
to young (15–30 years) married women. On the other hand, NFHS-3 collected information on dif-
ferent components of antenatal care (ANC) for the most recent birth and on delivery care for
all births in the last five years preceding the survey. So, women who had at least one birth in the five
years preceding the survey were considered for analysis.
2.2 Analytical Approaches
2.2.1 Conceptual Framework
A conceptual framework (Figure 1) was developed to represent the possible linkages among different
sets of variables included in the study. The main outcome of interest was MCH care utilization with
full ANC and institutional delivery as the two selected indicators. It was conceptualized that utiliza-
tion of MCH care would be determined through the interplay of a set of covariates like respon-
dents’ basic background characteristics, their empowerment and supportive social environment.
Domestic violence was considered as an important intermediate factor that might influence
health care utilization. The different variables included in the study are described below.
Outcome Variables
The major outcomes of interest were receipt of full antenatal care (ANC) and institutional deli-
very for the most recent birth. Full ANC was defined as receipt of three or more antenatal check-ups
(with the first check-up in the first trimester of pregnancy), two or more Tetanus Toxoid (TT) injections
Figure 1. Conceptual Framework
Atreyee Sinha and Aparajita Chattopadhyay
International Journal of Population Studies | 2016, Volume 2, Issue 2 111
and receipt of Iron and Folic Acid (IFA) tablets or syrup for three or more months (IIPS and Macro
International, 2007). Women who had received all these services were coded as ‘1’ (full ANC) and ‘0’
(no/ partial ANC) otherwise.
Delivery conducted in a medical institution or health centre was considered as an institutional de-
livery and institutional delivery or home delivery assisted by a doctor/nurse/LHV/ANM/other health
professional was termed as ‘safe delivery’ (WHO, 2006). If the delivery took place in any medical
institution the variable was coded as ‘1’ and ‘0’ otherwise.
Covariates
In the present study, a range of socio-economic and demographic factors that were likely to be
associated with MCH care use were controlled. Background characteristics of the respondents in-
cluded individual characteristics like age, place of residence, religion, caste, wealth index and type
of family. Two important birth related characteristics — birth order and pregnancy intension — were
also included as they had direct associations with the utilization of MCH care.
Women’s empowerment is a key factor for both women’s and children’s welfare (World Bank,
2012). In the present study, we included women’s educational attainment, working status, exposure
to mass media (any digital or print media), women’s ability to take decisions regarding their own
health, freedom of movement to health facility and most importantly, the experience of spousal vi-
olence as the components of women’s empowerment. The third set of factors included supportive
social environment which comprised of availability of money for health care, presence of female
provider at the health facility, geographic accessibility (distance to health facility), presence of hus-
band during ANC check-up and getting advice on delivery care during ANC check-up. It was as-
sumed that these three sets of confounding factors would determine the utilization of MCH care ser-
vices by young married women.
Physical/sexual Violence and Emotional Violence
Spousal violence was considered as a component of women’s empowerment and an intermediate
factor determining the use of MCH care. There were nine forms of physical and sexual violence
perpetrated by a husband: slapping, twisting arms or pulling hair, pushing/shaking/throwing some-
thing at wife, punching with fists or with something that could hurt wife, kicking/dragging/beating
up, trying to choke/burn on purpose, threatening/attacking with a knife or a gun or any other weapon,
physically forcing to have sexual intercourse even when wife did not want to, and forcing wife to
perform any sexual act that she did not want to. Respondents who said ‘yes’ to any of the nine forms
of physical or sexual violence were considered as abused women; abused women were given a code
of ‘1’ and ‘0’ for the non-abused. For emotional violence, female respondents were asked whether
their husbands ever said or did anything to humiliate her in front of others, threatened to hurt or
harm her or someone close to her and insulted her to make her feel bad about herself. Respondents
who answered ‘yes’ to any of the three forms of violence were considered to be emotionally abused
and coded as ‘1’; for those who said ‘no’ to all questions, ‘0’ was assigned.
Analysis
Analyses were performed separately for the North and South states to consider the regional varia-
tion in the utilization of maternal health care services. The analytical part of the paper had three dis-
tinct sections. First section dealt with the MCH care utilization in the two regions. Various indicators
depicting the levels of MCH care utilization were presented graphically. The second section pre-
sented the situation of women’s empowerment with special focus on spousal violence in both regions.
The last section examined the association of background characteristics, women’s empowerment and
supportive social environment with the utilization of MCH care services with a special focus on
spousal violence by applying binary logistic regressions.
3. Results
Selected socio-economic and demographic characteristics of the study population are presented in
Utilization of maternal and child health care services in North and South India: does spousal violence matter?
112 International Journal of Population Studies | 2016, Volume 2, Issue 2
Table 1 The major difference between the North states and the South states was observed by their
rural-urban residence and wealth status. In the North states, 81% of the selected women were from
rural areas and only 19% were from urban areas, whereas in the South states 41% were from urban
Table 1. Characteristics of young married women in selected North and South Indian states, based on NFHS-3 (2005–06).
Sample characteristics North Indian States (%) South Indian States (%)
Socio-economic characteristics:
Age (in completed years)
15–19 9.0 7.5
20–24 42.4 46.9
25–29 48.6 45.7
Religion
Hindu 83.5 83.3
Non-Hindu 16.5 16.7
Caste
General 20.2 27.3
Scheduled Caste & Scheduled Tribe 29.4 27.6
Other Backward Classes (OBC) 50.3 45.1
Place of Residence
Urban 19.3 41.2
Rural 80.7 58.8
Wealth index
Poor 58.4 28.7
Middle 18.3 25.0
Rich 23.3 46.3
Type of Family
Nuclear 50.8 55.3
Joint 49.2 44.7
Components of women's empowerment:
Education
No education 63.0 26.8
Primary 12.8 15.7
Secondary and higher 24.2 57.5
Work status
Not working 72.9 64.8
Working 27.1 35.2
Media exposure
No exposure 41.8 15.3
Any exposure 58.2 84.7
Allowed to go to the health facility alone
No 63.6 47.5
Yes 36.4 52.5
Has say in decision making in own health care
No 44.7 36.4
Yes 55.3 63.6
N 4837 3304
Note: Sample refers to young married women aged less than 30 years who gave birth in last 5 years preceding the survey.
Selected North Indian States: Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh; Selected South Indian States: Maharashtra, Andhra Pradesh and Tamil Nadu.
Atreyee Sinha and Aparajita Chattopadhyay
International Journal of Population Studies | 2016, Volume 2, Issue 2 113
areas and around 59% were from rural areas. Proportion of women belonging to poor economic
strata was 58% in the North followed by rich (23%) and middle class (18%). Whereas, in the South
the situation was quite different; proportion of women belonging to upper wealth index was more
(46%) than the poor (29%) and middle class (25%). Regional variation in the components of wom-
en’s empowerment was evident from the results. Women in the South states had higher educational
attainment, mass media exposure, higher mobility and decision making power compared to the
North states. More than half of the women (52.5%) from the South had freedom to go to health facil-
ity unescorted and around 64% women could make decisions on own health care. In the North,
the corresponding values were 36% and 55% respectively.
Levels of MCH care utilization varied across regions where the South states performed better
across all indicators of MCH care. Receipt of all recommended types of ANC for the last live birth
(Figure 2) was higher in the South. Receipt of delivery care (Figure 3) was higher among women in
the South as compared to the women in the North. In the South, 71% women delivered their
last child in a health centre, 22% gave birth to their last surviving child at home assisted by some
trained health personnel and only 7% delivered at home without any trained birth attendant. In the
North the corresponding figure to institutional delivery was disproportionately lower (23.4%). Home
delivery assisted by some trained health personnel was the highest (56.4%) in the North and more
than 20% of women delivered at home without any assistance from trained health personnel. Male
involvement in maternal care (Figure 4) was also found to be higher in the South states compared to
the North. For instance, when in the North 57% of women going for any ANC visit were accompa-
nied by their husbands in the last pregnancy, it was around 73% in the South.
Table 2A presents the level of spousal violence in the two regions and depicts a regional variation
in the experience of spousal violence. More than half (51.6%) of the women in the North states ex-
perienced any form of spousal violence (physical/sexual/emotional) ever in their lives and 39% ex-
perienced so in the last 12 months. The corresponding values were 34% and 26% respectively
among women in the South states. Experience of physical violence was the highest (45.7%) among
Figure 2. Receipt of Full Ante Natal Care by women in North and
South India.
Figure 3. Types of Delivery Care received by women in North and
South India.
Figure 4. Support received from husband during ANC check-ups in North and South India.
Utilization of maternal and child health care services in North and South India: does spousal violence matter?
114 International Journal of Population Studies | 2016, Volume 2, Issue 2
all types of violence in the North states followed by emotional (19.1%) and sexual violence (14.7%).
The prevalence was lesser among the South states for all three types of violence; around 32% wom-
en ever experienced physical violence, 14% reported emotional violence and only 2% experienced
sexual violence. A similar regional pattern was observed in case of experience of spousal violence in
the last 12 months. Among different forms of physical violence, slapping was the most common
form followed by twisting of arm, pushing/shaking/throwing something that could hurt the respon-
dent, kicking/dragging/beating up and punching with fist. In case of sexual violence, forced sex was
the most prevalent form than any other forceful sexual act. On the other hand, being humiliated in
front of others was the most common form of emotional violence. The overall prevalence of spousal
violence in its various forms (physical, sexual and emotional) was higher in the North states com-
pared to the South states.
There was a significant association among different forms of spousal violence in both regions
(Table 2B). Those who had experienced sexual and emotional violence ever in their lives were also
prone to experience physical violence in both regions. Similarly, women experiencing physical and
sexual violence also faced emotional violence in both regions. Proportion of women experiencing
sexual abuse among those who had experienced physical and emotional violence was greater in the
North. It can be concluded that experience of sexual and emotional violence occurred together with
physical violence.
Table 2. Prevalence of spousal violence in selected North and South Indian states, based on NFHS –3 (2005–06).
A. Experience of spousal violence by various forms: North (%) South (%)
Physical Violence
Any physical/sexual/emotional violence 51.6 33.8
Physical/sexual violence 48.7 31.7
Physical violence 45.7 31.6
sexual violence 14.7 2.4
Emotional violence 19.1 14.0
Any physical/sexual/emotional violence 39.1 26.4
Physical violence in the past 12 months 32.4 24.0
Experienced Sexual violence in the past 12 months 12.0 2.2
Physical/sexual violence in the past 12 months 36.4 24.3
Emotional violence in the past 12 months 14.4 10.8
Push/shook/threw something 17.2 8.6
Slap 44.7 30.5
Punch 14.0 6.0
Kick/drag 14.1 8.7
Strangle 2.5 0.6
Threatened 1.1 0.5
Twisted 18.6 12.8
Sexual violence
Forced sex 14.1 2.3
Other sexual acts 5.3 1.4
Emotional violence
Humiliated 15.5 12.2
Threatened to harm 5.9 4.9
Insulted 9.8 5.8
Atreyee Sinha and Aparajita Chattopadhyay
International Journal of Population Studies | 2016, Volume 2, Issue 2 115
B.
Ever experienced any
Physical violence (%) Ever experienced any
Sexual violence (%) Ever experienced any
Emotional violence (%) N =
North South North South North South North South
Ever experienced any Physical violence 25.7 7.4 34.7 37.3 2171 1063
Ever experienced any Sexual violence 79.9 96.7 47.4 53.3 665 89
Ever experienced any Emotional violence 83.0 84.3 36.5 9.3 915 421
Note: Sample refers to young married women aged less than 30 years who gave birth in last 5 years preceding the survey.
Selected North Indian States: Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh; Selected South Indian States: Maharashtra, Andhra Pradesh and Tamil Nadu.
Associations were found significant in the Chi-square test; p<0.001
The bi-variate associations between different components of MCH care and experience of spousal
violence were presented in Tables 3A and 3B. Results revealed that there was a significant regional
variation in the utilization of selected components of MCH care services by experience of spousal
violence. Abused women were more prone to delay their entry into antenatal care in the North states;
Table 3. Indicators of maternal and child health care by women’s experience of spousal violence in selected North and South Indian states, based on
NFHS-3 (2005–06).
A. Ever experience of any physical/sexual violence
North (%) South (%)
Experienced Not experienced Experienced Not experienced
Antenatal Care for last live birth:
Number of antenatal visits
At least 3 visits 25.8 34.6 79.4 86.7
Timing of 1st antenatal check-up
< 4 months (1st trimester) 42.9 47.5 64.2 75.0
Receipt of tetanus toxoid injections
At least 2 TT injections 68.9 74.8 86.0 89.0
Receipt of iron & folic acid tablets
Received for 90 & more days 8.2 16.3 31.2 44.4
Delivery care for last live birth:
Institutional delivery 21.1 29.1 64.6 75.8
Safe delivery 31.7 38.7 72.1 81.8
B. Ever experience of any form of emotional violence
Antenatal Care for last live birth:
Number of antenatal visits
At least 3 visits 29.0 31.0 76.7 85.7
Timing of 1st antenatal check-up
< 4 months (1st trimester) 44.0 46.0 64.3 72.8
Receipt of tetanus toxoid injections
At least 2 TT injections 71.0 72.1 87.9 88.1
Receipt of iron & folic acid tablets
Received for 90 & more days 7.9 13.4 29.4 42.0
Delivery care for last live birth:
Institutional delivery 20.8 26.2 59.8 74.3
Safe delivery 31.7 36.1 68.2 80.4
Note: Values are in percentages.
Selected North Indian States: Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh; Selected South Indian States: Maharashtra, Andhra Pradesh and Tamil Nadu.
Utilization of maternal and child health care services in North and South India: does spousal violence matter?
116 International Journal of Population Studies | 2016, Volume 2, Issue 2
women who had experienced any form of physical or sexual violence, only 26% of them had gone
for at least 3 ANC visits as compared to 35% of those who had not experienced violence. The pro-
portion of women entering ANC during 1st trimester was lesser (42.9%) among the abused women
than that of the non-abused women (47.5%). Receipt of at least 2 Tetanus Toxoid (TT) injections and
Iron and Folic Acid (IFA) tablets for 90 days or more were also smaller (68.9% and 8.2% respec-
tively) if the women were abused than their non-abused counterparts (74.8% and 16.3% respective-
ly). Likewise in the South states, receipt of ANC care declined if the respondents experienced any
physical/sexual violence.
In case of delivery care it was found that institutional delivery and safe delivery were also lower
among abused women in both regions. In the North states 21% and 32% of the abused women went
for institutional and safe delivery respectively, compared to 29% and 39% of the non-abused women.
Similarly, in the South a smaller proportion of the women who had experienced spousal violence,
delivered their last child in any health centre (65%) and availed safe delivery care (72%) compared
to those who did not experience spousal violence (76% and 82% respectively). Experience of emo-
tional violence also had similar constraining effects on MCH care utilization in the two regions.
Thus, a negative association between experience of spousal violence and the utilization of MCH care
service utilization was evident.
Results from binary logistic regression (Table 4) revealed that in the North states, women who
had experienced any form of physical or sexual violence were 21% less likely (OR= 0.79) to use all
recommended types of ANC care compared to women who had not experienced any violence. In the
South similar association was observed; abused women were 32% (OR= 0.68) less likely to use full
ANC. Quite interestingly, the constraining effects of spousal violence on receipt of full ANC was
stronger in the South states. In the North states women who had experienced any physical/sexual
violence were less likely to have an institutional delivery (i.e., deliver their child at a medical institu-
tion) or a home delivery assisted by a doctor, nurse, lady health worker, auxiliary nurse midwife, or
other health professionals. Association of physical/sexual abuse and delivery care was not significant
for the South states. Experience of emotional violence also had a negative relation with antenat-
al care service utilization in the South states; women facing any emotional violence were 22% less
likely to receive full ANC (OR= 0.78) although the association was relatively weak. Likelihood of
undergoing safe delivery was around 30% lower (OR= 0.70) for those women who had experienced
emotional violence in South states. The association between emotional violence and utilization of
maternal care was not significant for the North states.
When women’s background characteristics, and supportive social and environmental factors
were controlled, it was observed that women’s empowerment played a crucial role in the utilization
of MCH care services. Women with primary or higher levels of education were nearly 1.5 to 3 times
more likely to receive full ANC and avail institutional delivery in both regions. Women’s health care
decision making was an important factor for receipt of full ANC and institutional delivery; women
who had say in the decision on own health care were 1.3 times more likely (OR=1.30) to receive full
ANC in the South and 1.2 times more likely (OR=1.20) to deliver in health facilities in the North.
Women’s ability to go to health facility unescorted improved utilization of ANC and delivery care in
the North states. Any exposure to mass media also significantly increased the likelihood of receiving
full ANC in South and institutional delivery in both regions. Birth order was the most important de-
mographic factor determining the utilization of MCH care services in both regions. Mothers of high-
er birth order children, i.e., second and 3+ orders, were significantly less likely to receive all rec-
ommended types of ANC and deliver in institutions in both regions. To a certain extent, unwanted
pregnancies also affected the receipt of ANC and delivery care in the North states, although the as-
sociation was weak.
Atreyee Sinha and Aparajita Chattopadhyay
International Journal of Population Studies | 2016, Volume 2, Issue 2 117
Tab le 4. Odds ratios for receiving all recommended types of ANC services and availing institutional delivery among young married women (15-30
years) who gave birth during last five years preceding the survey in selected North and South Indian states.
All recommended types of ANC Institutional delivery
Exp(B) Exp(B)
North South North South
Ever experience of violence:
Any form of physical/sexual violence
No (1.00)
Yes 0.789+ 0.680*** 0.992* 1.119
Any form of emotional violence
No (1.00)
Yes 0.978 0.776 + 1.265 0.701*
Women's empowerment:
Education
No education (1.00)
Primary 1.611* 1.443* 1.327** 1.412*
Secondary and higher 2.562*** 1.958*** 1.791*** 3.026***
Work status
Not working (1.00)
Working 1.228 1.214* 1.002 0.869
Allowed to go to the health facility alone
No (1.00)
Yes 1.382** 0.922 1.165 + 1.169
Has say in decision making in own health care
No (1.00)
Yes 0.838 1.298** 1.204* 1.015
Media exposure
No exposure (1.00)
Any exposure 1.108 2.302*** 1.219 + 1.430*
Birth related factors:
Birth order
1 (1.00)
2 0.478*** 0.794* 0.515*** 0.608***
3+ 0.278*** 0.596*** 0.339*** 0.474***
Pregnancy intention
Wanted (1.00)
Not wanted 0.668* 0.985 0.854 + 1.178
Note: Control variables (not presented in the table) include different socio-economic characteristics (age of the mother, place of residence, religion, caste, and
wealth index), supportive social environment (father’s presence during ANC and advice for safe delivery) and availability & accessibility of services (money, distance
and female health provider).
Selected North Indian States: Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh; Selected South Indian States: Maharashtra, Andhra Pradesh and Tamil Nadu.
(1.00) Reference category; *** p<0.001, ** p <0.01, * p <0.05, + p <0.10
4. Discussion and Conclusions
The study brought out a few important factors that influenced the utilization of maternal health care
services. One of the most important factors was the mother’s education level. The present study
found a very strong influence of secondary and even primary level education on the antenatal care
Utilization of maternal and child health care services in North and South India: does spousal violence matter?
118 International Journal of Population Studies | 2016, Volume 2, Issue 2
and delivery care. Increasing education level ensured better utilization of healthcare services. As
suggested by many other studies, education empowers women over their circumstances in life
through proper knowledge and awareness. Educated women may have better communication with
family members, especially with husbands, and they may have the understanding of the value of
skilled health care which altogether may provide them the decision-making capacity to go for proper
health care for themselves, their children and other family members. Educated women have the
power to influence others’ decisions very subtly with their own knowledge, and ability to handle
adverse situations through in-depth understanding on different matters (Allendorf, 2010; Celik and
Hotchkiss, 2000; Furuta and Salway, 2006; Navaneetham and Dharmalingam, 2002; Singh, Rai and
Singh, 2012). Women’s autonomy does not have much effect on MCH service utilization (Singh, Rai
and Singh, 2012), but when its components like the ability to take decision on own health care,
freedom to go to the health facilities, media exposure are considered separately, women’s autonomy
is found to be positively related to utilization of health care services. Women who have the ability to
decide on own healthcare related issues are more likely to receive antenatal care and safe deli-
very care (Bloom, Wypij and Dasgupta, 2000). Birth order and, to some extent, unintended pregnan-
cies of the women negatively influenced MCH service utilization. These results were consistent with
the findings from other studies (Singh, Rai and Singh, 2012; Celik and Hotchkiss, 2000; Santhya,
Jejeebhoy and Ghosh, 2008). The possible reasons behind this may be the fact that usually
people become more concerned about the first pregnancy due to the chances of many related com-
plications and non-experience of the mother but for later pregnancies mothers may feel more confi-
dent and knowledgeable about the pregnancy care and related matters. This may restrict them to go
for skilled care during subsequent pregnancies. Sometimes higher birth order means that the family
size is bigger and economic constraints can also be a major hindrance in this regard to receive
health care service utilization (Raj, Saggurti, Balaiah et al., 2009).
Spousal violence is not a very relevant factor in explaining the use of all the maternal health care
services, especially in the case of institutional delivery. The differences found in use of MCH care
services between women who did and did not experience spousal violence can probably be explained
to a large extent by other factors such as education, wealth status, birth order and exposure to mass
media. However, in case of availing ANC services, experience of physical/sexual violence had a
strong negative influence. Therefore, any form of spousal violence can be considered as an important
determinant of the well-being of women and children in the North and South Indian states. Expe-
riencing violence in the hands of their intimate partners tends to lower the self-esteem among wom-
en and they in turn become reluctant to take proper care of themselves (Higgins, 2011). These wom-
en lack physical, mental and financial freedom and decision-making authority to avail health care
services during pregnancy. The presence of violence also reduces their power to negotiate for their
own rights, make right choices in life and thus it may eventually affect their access to quality
health care (Singh, Mahapatra and Datta, 2008).
A regional disparity in the levels of utilization of health care services clearly came out from the
study. The selected South Indian states performed better than the North Indian states in this regard,
irrespective of the levels of spousal violence. Such differences could partly be linked to the regional
diversity in terms of availability of resources and the states’ socioeconomic progress (Dyson and
Moore, 1983). The states covered under the North Indian region namely Rajasthan, Madhya Pradesh,
Uttar Pradesh and Bihar are Empowered Action Group States (EAG) or priority states as referred by
the Government of India. These states are characterized by low female literacy, poor exposure to
mass media, low age at marriage, high fertility and lower status of women. However, when the indi-
cators of development status were controlled, spousal violence still had similar negative effects on
MCH care use in both regions. It is worth mentioning that contrary to our hypotheses, spousal vi-
olence had a stronger influence in reducing the receipt of full ANC care and institutional delivery
among women in the South Indian states. The reason for such stronger influence in the South is that,
when acceptance of spousal violence is culturally embedded its occurrence is also high, as observed
Atreyee Sinha and Aparajita Chattopadhyay
International Journal of Population Studies | 2016, Volume 2, Issue 2 119
in the North (Bauer, Rodriguez, Quiroga et al., 2000; Chandrasekaran, Krupp, George et al., 2007;
Hughes, 2004). In such cases, the victims do not perceive themselves to be victimised and tend to
accept violence as a justified action by husbands (Heise, Ellsberg and Gottmoeller, 2002). Given this
attitude towards domestic violence from the victims themselves, it is not surprising that nearly 51%
of the married men and 54% of married women think that beating of wives is acceptable for certain
specific reasons, particularly if she disrespects her in-laws (IIPS and Macro International, 2007).
This type of attitude is more in the Northern part of the country than the South. On the other hand,
when incidence of violence is less in society (as in the South states), women tend to feel more victi-
mised and isolated and thus the impact of such violence becomes manifold, as we observed in the
South Indian states. Consequently we see that the effect of violence on lowering MCH care utiliza-
tion is more serious among the victims in the South rather than in the North.
One potential drawback, that needs to be taken into account, is that the present study used cross-
sectional data. Due to the nature of data, the major limitation of the analysis was our inability to un-
derstand the exact temporal relationship between occurrence of violence and the utilization of
MCH care. We were unable to determine whether the violence occurred before or after the
MCH care utilization. However, women’s age was restricted to 15–30 years in order to take care of
this temporality issue. In India, at older age groups, i.e., above 30 years, incidence of violence re-
duces gradually. The chances of pregnancy also decline significantly as the women grow older (IIPS
and Macro international, 2007). The median age at marriage in India is less than 20 years and the
first onset of spousal violence is within first 2 years of marriage (IIPS and Macro International,
2007). Thus, by considering young married women we tried to capture recent episodes of spousal
violence as well as recent pregnancy.
The present study highlighted the constraining effects of spousal violence on the uptake of mater-
nal and child health care services among young married women in India and thus the issue of spous-
al violence calls for attention from the policy makers and stakeholders on priority basis. First and
foremost the reproductive and child health programs should address spousal violence in order to im-
prove health and well-being of women coming to the facilities for treatment. Integration of violence
screening with the MCH care programs could be helpful in identifying the victims, providing prop-
er care and support to them and thus improving the coverage of health care services simultaneously.
Promoting women’s empowerment by specifically improving female education is a key to combat
incidence of violence as well as increase the awareness and utilization of health care services in the
long run. Since education and media exposure have a very strong association with health care utili-
zation across the regions, it is necessary for the national level policies to use print and digital media
and target educational institutes in order to create awareness about MCH programs among women.
Along with focusing on the victims, policies should also focus on the perpetrators of violence. In-
volvement of men in the reproductive and child health programs and counselling them can also be a
key in reducing intimate partner violence. Policies aiming at gender sensitization at early ages, i.e.,
among school students, during marriages and in health centres are also imperative. Promoting exist-
ing policies and laws of violence prevention through media, advertising the importance of MCH care
services with its short and long term implications, encouraging men to be a part of the MCH care
programs and above all strengthening women's voice against spousal violence are the need of the
hour.
Conflict of Interest and Funding
No conflict of interest was reported by all authors. The analysis described in this paper was based on
secondary data obtained from publicly available sources and no funding was obtained from any ex-
ternal sources to prepare this article.
Acknowledgements
We express thanks to the editor and the two anonymous reviewers of this journal for their useful
Utilization of maternal and child health care services in North and South India: does spousal violence matter?
120 International Journal of Population Studies | 2016, Volume 2, Issue 2
and constructive comments. We are appreciative to Professor Jaikisan Desai for his valuable inputs
and views on our manuscript. Editorial assistance of Mr. Pranab Kr. Das has helped us to improve
the quality of the paper.
Author Contributions
Atreyee Sinha and Aparajita Chattopadhyay have jointly led the paper. Aparajita Chattopadhyay
played a key role while conceptualizing the paper. Atreyee Sinha analyzed the data, drafted the first
manuscript and also revised the manuscript subsequently. Aparajita Chattopadhyay helped with her
inputs in revising the paper.
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