The World Health Organization (WHO) defines intimate partner violence (IPV) against women as a behavior within an intimate relationship that causes physical, sexual and psychological harm including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviors by current or former male intimate partner[1]. It is considered as a gross human rights violation[2] with lasting negative impact on women's health[3]. The impact is severe when it happens during pregnancy as the fetus and the newborn could also be affected negatively[4].
Intimate Partner Violence during Pregnancy (IPVP) is widely prevalent in Africa, particularly in Sub-Saharan Africa, with an estimate of 2.3–57.1% women in the region experiencing it anytime during their pregnancy period[5]. In Ethiopia, the prevalence of IPV during pregnancy generally varies between 4% and 58.7% [6, 7]. Wife beating, husband's controlling behaviors and marital forced sex are widely accepted and justified practices in the country due to the socio-cultural dynamics that put women in subordinate position relative to men[8, 9].
Neonatal mortality, death which occurs during the first 28 days of life, contributes to 2.5 million deaths globally, where the vast majority of these deaths (89%) arises from low and lower-middle income countries[10]. Sub-Saharan Africa has the highest share of burden in neonatal mortality [11]. In Ethiopia, national estimate in neonatal mortality rate in 2016 was as high as 29 deaths per 1000 live births which accounts 60.4% of the infant mortality[7]. Despite a significant reduction of 60% in under-five mortality in the years between 2000 and 2016, a relatively lower rate of decrease in neonatal mortality was achieved (41%) in the same time period [7]. Given this rate of decrease in neonatal mortality, it might be a big challenge to reach the target the country set to reduce a neonatal mortality rate of 10 per 1000 live births by end of 2020[12].
Available evidences suggest that IPV perpetrated during pregnancy could lead to elevated risks of neonatal death [13–16]. Different theoretical explanations have been provided on the pathways through which IPV during pregnancy lead to the increased risk of neonatal/newborn death. One pathway is that exposure to various forms of abuse during pregnancy is associated with poor maternal nutrition[4] and elevated maternal stress levels[17], both of which are linked with low infant birth weights[18–20], which when combined with poor neonatal nursing of the abused mothers[21] can contribute for increased risks of neonatal death[22, 23]. The other possible pathway is that women in abusive or controlled relationships might have limited household decision autonomy and use of MCH services[24] which could indirectly contribute to poor newborn health and survival [25, 26]. Chronic physical trauma, maternal sexual transmitted infections and pregnancy complications are also in a casual pathway between violence experienced during pregnancy and elevated risk of newborn deaths[17, 25].
Apart from IPV, socio-economic as well as obstetric and neonatal factors have been described by the Mosley and Chen conceptual framework on child survival[27]. Prior studies in Ethiopia documented risk factors such as young age at pregnancy or birth [28, 29], living in rural area [29] and no or lower level of educational or employment status [30, 31], which all relate to availability and use of limited resources in taking care of children that would indirectly contribute to the neonatal survival. Pregnancy and obstetric factors such as poor utilization of ANC, PNC or immunizations [28, 32, 33]; high gravidity and parity[28, 30]; births occurring at home[32]; low birth weight[28, 32, 33] and multiple (as opposed to singleton) form of deliveries [28, 33] have been extensively studied in the country. Moreover, maternal health risk related behaviors such as poor nutrition intake, alcohol abuse and smoking in pregnancy were also indicated as indirect risk factors for neonatal mortality [32, 34–36].
Despite recent evidences suggest association between deaths in newborns/neonates and experience of IPV during pregnancy in the developing world [15, 37], and particularly in East Africa[38], evidence in this interlink are hugely lacking in Ethiopia. The aim of this study is, therefore, to examine the association of different forms of intimate partner abuse during pregnancy (i.e., physical, sexual and psychological violence and husband/partner controlling behavior) and neonatal mortality using a community based matched case-control study in the Eastern part of Ethiopia.