اثرات نابرابری جنسیتی در سطح جامعه بر خشونت خانگی و بارداری ناخواسته در کلمبیا: آزمون دیدگاه فمینیستی

Violence against women, especially by intimate partners, is a serious public health problem that is associated with physical, reproductive, and mental health consequences. The effect of intimate partner violence on women's ability to control their fertility and the mechanisms through which these phenomena are related merit further investigation. Building on findings from a previous analysis in which a statistically significant relationship between intimate partner violence and unintended pregnancy in Colombia was found, this analysis examines the effect of gender inequality on this association using data from the 2000 Colombian Demographic and Health Survey. Specifically, the objective of this analysis is to explore whether gender inequality (as measured by women's autonomy, women's status, male patriarchal control, and intimate partner violence) in municipalities partially explains the association between intimate partner violence and unintended pregnancy in Colombia. Results of logistic regression analysis with multi-level data show that living in a municipality with high rates of male patriarchal control significantly increased women's odds of having an unintended pregnancy by almost four times. Also, living in a municipality with high rates of intimate partner violence increased one's odds of unintended pregnancy by more than 2.5 times, and non-abused women living in municipalities with high rates of intimate partner violence were at a significantly increased risk of unintended pregnancy. In addition, abused women living in a municipality with high personal female decision-making autonomy had more than a fourfold increased risk of having an unintended pregnancy. These findings demonstrate the need for reproductive health programs to target areas at particularly high risk for unintended pregnancy by reducing intimate partner violence and gender inequality.

Violence against women, especially by intimate partners, is a serious public health problem that is associated with physical, reproductive, and mental health consequences (Campbell et al., 2002; Heise, Ellsberg, & Gottemoeller, 1999; Moore, 1999; Golding, 1999). Health consequences and adverse pregnancy outcomes can result from direct trauma (Fildes, Reed, Jones, Martin, & Barrett, 1992; Ribe, Teggatz, & Harvey, 1993) or stress-related responses from the psychological stress associated with intimate partner violence (IPV) (Altarac & Strobino, 2002; Schei & Bakketeig, 1989; Newton & Hunt, 1984). Another less explored mechanism through which intimate partner violence can affect women's health is by living in an environment where there is a risk or threat of abuse by an intimate partner. This can lead to lack of control over sexual decision-making and contraceptive use, which can lead to unintended pregnancy. However, only scarce international research is available regarding the relationship between intimate partner violence and women's ability to control their own fertility. According to recent estimates, up to 100,000 cases of maternal deaths and 4.6 million disability adjusted life years (DALYs) could be prevented globally if women could prevent unintended pregnancies (Butler, 2003). In addition, other adverse outcomes have been associated with unintended pregnancies, including maternal deaths and complications due to illegal abortions (Henshaw, Singh, & Haas, 1999; Ladipo, 1989; Magadi, 2003; Okonofua, Odimegwu, Ajabor, Daru, & Johnson, 1999), perinatal mortality and pregnancy complications (Laukaran & van den Berg, 1980; Bustan & Coker, 1994), late entry into prenatal care (Eggleston, 2000; Gage, 1998; Joyce & Grossman, 1990; Kost, Landry, & Darroch, 1998; Marsiglio & Mott, 1988; Marston & Cleland, 2003), low birthweight (Laukaran & van den Berg, 1980; Marsiglio & Mott, 1988) and very low birthweight infants (Sable et al., 1997), lower likelihood of breastfeeding (Chinebuah & Perez-Escamilla, 2001; Dye, Wojtowycz, Aubry, Quade, & Kilburn, 1997), as well as risks to women's health (Conde-Agudelo & Belizán, 2000; King, 2003) or fetal and infant health (Khoshnood, Lee, Wall, Hsieh, & Mittendorf, 1998; King, 2003; Klerman, Cliver, & Goldenberg, 1998; Smith, Pell, & Dobbie, 2003) when the pregnancies are closely spaced. With the exception of a few studies conducted in the United States using data from the Pregnancy Risk Assessment Monitoring System (PRAMS) (Goodwin et al., 2000; Gazmararian et al., 1995) and a recent study from Colombia (Pallitto & O’Campo, in press), little quantitative research directly explores the relationship between intimate partner violence and lack of fertility control. Each of these studies found statistically significant associations between intimate partner violence and unintended pregnancy, and the study from Colombia was the first to document this association in a developing country after controlling for confounding factors. A few other studies have indirectly explored the relationship between intimate partner violence and unintended pregnancy and found that abused women had higher rates of abortion history or unintended pregnancies than non-abused women, but these studies did not control for confounding factors (Amaro, Fried, Cabral, & Zuckerman, 1990; Hillard, 1985; Jacoby, Gorenflo, Black, Wunderlich, & Eyler, 1999; Martin et al., 1999; Stewart & Cecutti, 1993; Yoshihama & Sorenson, 1994). Other researchers explored women's abuse history among abortion patients (Evins & Chescheir, 1996; Glander, Moore, Michielutte, & Parsons, 1998; Leung, Leung, Chan, & Ho, 2002), and one study found significantly higher rates of abuse among abortion patients as compared to gynecological patients (Leung et al., 2002), but these studies also failed to control for confounding factors. Women's status in Colombia is undergoing important changes that are reflected in the fertility patterns of the country as well as in the passage of legislation regarding family violence (Ojeda, Ordoñez, & Ochoa, 2000), which makes it an interesting setting for understanding the effects of gender inequality on intimate partner violence and unintended pregnancy. Colombia is considered to be in the late intermediate stage of fertility transition (Brea, 2003), and fertility rates have decreased drastically from 6.8 in the early 1960s (Ordoñez et al., 1995) to 2.6 in 2000 (Ojeda et al., 2000). These changes are also reflected in women's contraceptive use patterns over time. According to the 2000 DHS data, 64% of women were currently using a modern form of contraceptive, and 89.4% reported ever use of modern contraceptive. Increases in current use rates of any method (modern or other) can be observed over the last several administrations of the DHS surveys: 72% in 1995, 66% in 1990, and 64% in 1986 (Ordoñez et al., 1995), however, unmet need for contraceptive use is estimated to be 6.2%. It is estimated that the total fertility rate would drop from 2.6 to 1.8 if women's pregnancy desires matched their actual fertility rates (Ojeda et al., 2000). Given the rapid changes occurring in women's status in Colombia (Ordoñez et al., 1995), as well as the significant association found between intimate partner violence and unintended pregnancy (Pallitto & O’Campo, in press) and evidence of regional variation within the country (Ojeda et al., 2000), further investigation of the dynamics of these phenomena is warranted. The purpose of this paper is to build upon the existing evidence of a statistical association between intimate partner violence and unintended pregnancy in Colombia by exploring whether variations in gender inequality (measured as women's autonomy and status and male patriarchal control) at the community level can help explain the mechanism through which intimate partner violence and unintended pregnancy are related.