STRENGTHS AND LIMITATIONS OF THIS STUDY
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The study compares the association between maternal exposure to intimate partner violence (IPV) and child stunting in four South Asian countries.
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The study has a large sample size.
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The relationship between maternal IPV and stunting varies among countries and may be more related to other sociodemographic and cultural factors, which are not available in the Demographic Health Survey data.
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The data used in the study were based on a cross-sectional survey, therefore, temporality between IPV and stunting cannot be assessed.
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A reverse causal mechanism between IPV and stunting is possible where child stunting may contribute to maternal IPV.
Introduction
Intimate partner violence (IPV), characterised by coercive and assaultive sexual and non-sexual acts, including physical and emotional violence, has been recognised as a prevalent form of violence against women worldwide, particularly among those aged 15–49 years. According to the WHO, nearly one-third of ever-married women globally (27%) experience physical and sexual or both types of IPV during their lifetime.1 2 Moreover, the rates of physical and sexual violence are substantially higher in developing countries as compared with developed countries.1 3 A meta-analysis of 141 studies conducted across 81 countries reported that 30% of women were subjected to IPV, with the highest frequency observed in sub-Saharan African countries, followed by South Asian countries.4 The most recent analysis conducted by the WHO on the data available from 2000 to 2018 for 161 countries and areas reported considerably higher rates of IPV incidence in South Asian and sub-Saharan African countries compared with regions such as Europe, Central Asia, East Asia, South East Asia, Australia and New Zealand.5 Consequently, IPV against women emerges as a global issue with potential significant ramifications, particularly for mothers—the primary caregivers of children.
Women experiencing IPV may face adverse health outcomes and behaviours during pregnancy, leading to unfavourable pregnancy outcomes.6 IPV can have both direct and indirect effects. Physical abuse during pregnancy can result in injuries, impacting pregnancy outcomes including miscarriages and maternal and fetal mortality.7 Research suggests that women subjected to IPV are more likely to miss prenatal check-ups, potentially resulting in adverse pregnancy outcomes such as low birthweight and preterm births.8 9 Maternal IPV is also linked to poor nutrition and inadequate weight gain during pregnancy,10 as well as increased stress and depression which indirectly affect maternal and neonatal outcomes by exacerbating pre-existing conditions such as diabetes and hypertension as well as by affecting their health-seeking behaviours.11 Pregnant women experiencing IPV may experience poor pre and antenatal health, leading to delays in prenatal and antenatal care and potentially resulting in fetal death, preterm birth, low birthweight and small for gestational age infants.6 9 These outcomes may significantly impact a child’s early growth and physical development, potentially leading to stunting and wasting.12 13 Furthermore, postchildbirth IPV experiences may contribute to child neglect and compromised infant care.14 Inadequate psychosocial, nutritional and medical care during infancy could hinder a child’s early growth, as mothers facing IPV may have compromised mental health, which can impede their ability to adequately care for their child, ultimately contributing to child malnutrition.15 The embryonic and early childhood phases are critical for developing biological regulatory systems that respond to stress, influencing both physical and mental health later in life. Research indicates that nutrition and lifestyle factors during and prior to pregnancy, as well as early childhood, have enduring effects on a child’s physical and mental health.16 17 A systematic data analysis from 31 studies also showed how IPV could negatively impact early child growth.18 The study concluded that maternal exposure to IPV increases the mother’s prenatal risk behaviours and reduces prenatal care usage, leading to adverse pregnancy outcomes such as impaired fetal growth.18 Other LMIC (low and middle income countries) studies have shown that mothers exposed to IPV are more likely to face poor pregnancy outcomes, such as fetal death, low birthweight and preterm birth,6 9 with their children facing increased mortality,19 lower mean weight-for-height z-scores14 and height-for-age z-scores (HAZ).20
Impaired growth and stunting are major public health issues associated with mortality and morbidity of children under 5 years of age.21 22 Approximately 56% of children globally suffer from stunting.23 Stunting contributes to short-term and long-term health challenges, affecting both physical and cognitive development,24 increasing vulnerability to infections and heightening the risk of chronic non-communicable diseases.16 25 A substantial portion of children in developing regions such as South Asia and sub-Saharan Africa face adverse socioeconomic conditions including poverty, malnutrition, inadequate childcare and child abuse, which collectively contribute to malnutrition.26 27 However, despite the critical role of maternal experiences in child development, the prevalence of maternal IPV exposure has been inadequately studied. Despite abundant evidence suggesting IPV as a potential predictor of a child’s impaired growth, the results across studies remain inconsistent and varied. Research conducted in African and Latin American nations, using data from the Demographic Health Survey (DHS), revealed a positive link between maternal exposure to physical IPV and child stunting19 and malnutrition.13 As per the results of five national DHS, children in a particular country had an increased likelihood of experiencing stunting if their mothers had been subjected to physical or sexual violence since the age of 15.19 While DHS data analysis has yielded valuable insights into the prevalence of violence against ever-married women across multiple countries28; the potential consequences of IPV on child outcomes and the intricate relationship between maternal exposure to IPV and child stunting remain areas that warrant further exploration.
Researchers have only recently begun to acknowledge the manifold adverse effects of IPV on mothers and its potential impact on their young children. Despite the significant gaps in this field and its ongoing exploration, young children remain disproportionately exposed to IPV due to their high dependency on caregivers for early care. The nutritional well-being of young children could be compromised due to their mothers’ exposure to IPV. However, research into this relationship is still limited, and the available data exhibit inconsistencies, especially in LMICs. We found various limitations in previous similar studies. A study by Chai et al investigated this relationship across 29 LMICs using pooled estimates and unweighted sampling. However, this approach cannot adequately capture the association within individual countries, given the distinct cultural, religious and racial aspects that differentiate LMICs. Another recent study by Inamdar et al29 explored the association between IPV driven by women’s empowerment and its impact on child stunting. However, a comprehensive and direct association was not adequately explored. The probable reasons for the limited exploration and inconsistent findings could stem from the absence of a specific case-specific definition of IPV. The categories often overlap and are disaggregated, particularly in the case of sexual and emotional IPV. Additionally, the acceptance and acknowledgement of such acts, where there are no apparent injuries, are uncommon. This could lead to the underestimation of emotional IPV, specifically emotional IPV. The rationale for not including emotional abuse in the study was to focus on specific and measurable outcomes. Unlike physical and sexual abuse, which often leave visible or documented signs and have more standardised criteria for identification, emotional abuse can be highly subjective and challenging to quantify accurately. Additionally, emotional abuse might manifest differently across diverse cultural contexts, making it harder to establish a universal set of criteria for identification. By narrowing the focus to physical and sexual abuse, the study aimed for a more concrete and objective analysis, ensuring the reliability and consistency of the data collected. This selective focus allows for a more in-depth analysis of the chosen types of abuse, leading to a comprehensive understanding of their impact on maternal and child health without the potential complications arising from the subjective nature of emotional abuse reporting. Therefore, this paper specifically focuses on women with exposure to physical and/or sexual IPV. Its primary aim is to determine the direct association between IPV (physical, sexual or both) and stunting, using DHS data from four South Asian countries. Weighted sampling techniques are employed, which are crucial for analysing data derived from complex survey designs. This study will highlight factors related to stunting that could contribute to the development and use of a more holistic and comprehensive approach towards stunting prevention among children in South Asia. The prevention strategies encompass the prevention of physical, sexual or both types of IPV.
Methods
Data source
This paper uses data from the DHS, which provides a comprehensive dataset covering a wide range of monitoring indicators related to maternal and child health and nutrition. The data are freely accessible online, and all identifier information is kept confidential. The data collected as part of DHS are comparable due to the standardised methods used across all survey sites. The DHS has been instrumental in collecting data on population demographics, health and nutrition indicators. The DHS 7 comprises four model questionnaires: a household questionnaire, a woman’s questionnaire, a man’s questionnaire and a biomarker questionnaire. In developing countries, the DHS collects nationally representative data based on standardised multistage sampling, predominantly two-staged and applies weighting. A primary sampling unit was used in this analysis. Household weight variables (along with specified stratification units within the datasets) were used for data weighting.30 Data from the DHS-7 in South Asian Countries including Pakistan (2017–2018), India (2015–2016), Nepal (2016), Maldives (2016–2017) were extracted and analysed to determine the association between maternal exposure to IPV and child stunting. Data from Bangladesh and Afghanistan were excluded due to missing information on IPV and anthropometric measurements.
Study variables
Explanatory variable
We extracted data from the Domestic Violence module of the DHS which was administered to women of reproductive ages (15–49 years). One married woman was randomly selected from each household, with the criteria of having at least one child less than 5 years of age and complete anthropometric measurements available for that child. The modified Conflict Tactic Scale (CTS) was used to measure IPV within the DHS dataset. The CTS is widely used for assessing IPV.13 31 IPV was considered the primary exposure, and respondents were questioned about their experiences of specific acts of physical and sexual violence perpetrated by a current or former spouse. For our study, IPV was defined as physical acts of harm such as broken teeth, broken bones, burns, attempts to strangulate or hurt with a sharp object such as a knife. In contrast, sexual violence was defined as sexual acts of harm such as being forced for unwanted sexual activity and forced with threats or in any other way to perform sexual acts against women’s wish. We defined IPV in two ways: (1) maternal exposure to any form of IPV versus none and (2) maternal exposure to different categories of IPV versus none, namely physical IPV only, sexual IPV only, physical and sexual IPV both. The time frame for assessing IPV was defined as a lifetime exposure, spanning from the age of 15 years onward.
Outcome variable
The outcome variable in this analysis was stunting, which is a strong indicator of child malnutrition and impaired growth, reflecting long-term nutritional deficiency. Standardised indicators of child stunting were employed, derived from anthropometric measurements taken for children aged between 0 and 5 years. These measurements were then standardised into Z-scores, quantifying the number of SD away from the median of a reference population (WHO Child Growth Standards). The outcome was further classified into moderate and severe stunting, identified by the height-for-age variable in children aged 6–59 months old defined by the WHO global database on child growth and malnutrition,32 which measures stunting in HAZ. An HAZ below −2 SD denotes moderate stunting, while an HAZ below −3 SD corresponds to severe stunting. Data records displaying Z-scores lower than −6 or exceeding +6 were deemed inaccurate and thus deduced from the analysis.13
Control variable
This analysis took into account potential confounding factors, including maternal age, parental education (both maternal and paternal), occupation, area of residence (whether rural or urban) and socioeconomic status. These factors were adjusted for in the analysis.13 Socioeconomic status was assessed using the wealth index measure. The wealth index is a composite measure which is calculated using a household’s ownership of selected assets, materials used for housing construction, and types of water access and sanitation facilities by principal component analysis.
Eligibility criteria
For this study, specific records that met the following criteria were included:
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Geographical focus: Data from the DHS-7 conducted in South Asian Countries, specifically Pakistan (2017–2018), India (2015–2016), Nepal (2016) and Maldives (2016–2017), were included.
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Participant selection: Individual records of married women (write age bracket here) from each household were included. These women had to fulfil several conditions: they were married, had at least one child under the age of 5 years, provided complete anthropometric measurements for the child and had a completed record of the IPV module, specifically items related to physical and sexual abuse. If multiple children were present, the youngest child’s record was chosen.
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Exclusion criteria for anthropometric data: Records displaying Z-scores lower than −6 or exceeding +6 were identified as inaccurate and were thus excluded from the analysis. Z-scores, indicating SD from the mean, were used to detect extreme values, which could indicate potential measurement errors.
Sample size
Table 1 presents the final sample sizes for available women and child-level data. With the exception of India (8.62%), all other counties exhibited response rates exceeding 10% for IPV data. Conversely, the Maldives, despite having the lowest count of eligible women’s responses (n=3026), demonstrated the highest response rate (39.30%). Overall, the missing data on women’s attributes were due to incomplete or missing information on IPV exposure and a lack of information on the birth records of the women. Missing IPV data comprise respondents who were ineligible for the domestic violence module, who had not given consent to participate, respondents who reported privacy issues at the interview or the selected interviewees who could not be interviewed due to any other reasons. The total eligible children’s observations were highest for India (n=167 969). A substantial portion of anthropometric data was lost due to missing or flagged nutrition indices, including missing height-for-age records. The analysis exclusively considered records for the indexed child (ie, the last child of the respondent).
Final sample sizes for women and children’s available records after data cleaning
Statistical analysis
The descriptive analysis included measuring frequencies and percentages of IPV, and stunting reported for each country. The inferential analysis employed a Cox proportional regression method run separately on each country’s data to assess the association between maternal exposure to IPV in moderate and severe stunting. Prevalence ORs, both crude and adjusted, were computed alongside 95% CIs. A stepwise forward approach was used for variable inclusion in the adjusted models, which controlled for all potential confounders through multivariable regression analysis. These adjusted models were applied uniformly to the data from each country. A significance level of p≤0.05 was considered to indicate statistical significance. All analyses were performed on Stata software V.16.0, while taking into account sample frequency weights to ensure the replication of a nationally representative population, as outlined in the DHS guide.
Patient and public involvement
Participants were not involved in the designing of this study. The manuscript is based on secondary data of DHS which is available in a public domain and openly available on the DHS website.
Results
Descriptive data
The descriptive data for the respondents in table 2 show that most of the mothers from the four countries were between 25 and 29 years of age, except for Nepal, where 40.8% of mothers were under 25. The respondents from Pakistan, India and Nepal were primarily uneducated, while in the Maldives, very few (1.1%) of the respondents reported having received no education. In Nepal (15.1%), Maldives (9.7%) and India (12.6%), the majority of the respondents had less than four children, while 37.36% of Pakistani women reported having four or more children. Across all four countries, the preponderance of respondents hailed from the most economically disadvantaged stratum. Notably, the disparity in responses between the least and most affluent brackets displayed minimal variance in Pakistan, indicating a mere 2.6% difference between these socioeconomic segments. A similar pattern emerged in India, while in the Maldives and Nepal, a notable concentration of responses originated from the lower wealth ranking strata, diverging significantly from the higher wealth ranking strata. Furthermore, the respondents from Pakistan, India and the Maldives predominantly emanated from rural areas.
Characteristics of mothers 15–49 years for the four South Asian countries
The burden of maternal exposure to IPV and stunting by countries is illustrated in figures 1 and 2, respectively. The prevalence of ever-experiencing IPV among women since the age of 15 years ranged from 10.2% (Maldives) to 31% (India). Notably, the highest prevalence of physical IPV only was observed in India (23.6%), closely followed by Pakistan (21.7%). Nepal reported the highest prevalence of sexual IPV (2.2%). However, the combined burden of both types of IPV was most pronounced in India (6.1%). Regarding child stunting, the prevalence in the samples varied from 14.0% (Maldives) to 35.9% (Pakistan). Furthermore, the prevalence of severe child stunting was notably higher in Pakistan (16.6%), followed by India (14.8%). In contrast, Maldives exhibited the lowest prevalence of maternal exposure to IPV across all three categories of IPV as well as stunting.
The bar graph shows the number of cases of maternal exposure to IPV in the four South Asian countries. IPV, intimate partner violence.
The bar graph showing the number of stunted child outcomes in the four South Asian countries.
In table 3, India demonstrates a significant association between IPV and overall moderate to severe stunting, after adjusting for maternal age, education, number of children, household wealth ranking and place of residence. In table 4, Nepal exhibits a significant association between physical IPV alone and severe stunting, following adjustment.
Crude and adjusted prevalence ORs of the association between maternal experience of IPV and overall child stunting
Crude and adjusted prevalence ORs of the association between maternal experience of IPV and severe child stunting
The overall burden of stunting in South Asia is known to be high; however, our results show that women who have experienced IPV have a higher prevalence of both moderate and severe stunting. For example, the prevalence of moderate stunting among ever-abused women in Pakistan is 21%, while it is 18% among never-abused women. Similarly, the prevalence of severe stunting is 18% among ever-abused women, whereas it is 16% among never-abused women. The same trend is observed in the data from each country. Thus, we deduce that children of women who have suffered from IPV are at a higher risk of stunting compared with those women who have never been abused (online supplemental table 1).
Supplemental material
Discussion
We investigated the association between maternal experiences of IPV and child stunting in four South Asian countries using nationally representative surveys. Our analysis yielded varied results regarding the association between IPV and child stunting across these countries, which can be attributed to potential measurement errors. Employing advanced modelling techniques could offer a clearer understanding of this association. Specifically, we observed significant crude associations between IPV and stunting, as well as severe stunting, in Nepal, Maldives and India. Additionally, except for Pakistan and Maldives, physical IPV demonstrated both significant crude and adjusted associations with overall child stunting. Only Nepal reported the adjusted association between physical IPV and severe child stunting in this analysis. Maternal exposure to IPV substantially increased the risk of child stunting. Notably, similar associations have been observed in single-country studies conducted in Bangladesh, Brazil, Haiti, India and Kenya.13 31 33 34 In countries such as Pakistan and other South Asian countries, IPV often thrives due to male-dominant societal norms and the influence of cultural beliefs that establish men as superior and dominant figures. In these LMICs, factors such as poor socioeconomic status and high illiteracy rates further contribute to IPV, perpetuating male dominance. Exploring the impact of IPV on maternal and child outcomes requires distinguishing between authors’ hypotheses rooted in cultural norms and plausible alternatives, considering the complex interplay between IPV and societal dynamics.
Our study also revealed a significant association between maternal exposure to both physical and sexual IPV and its relationship with moderate to severe stunting, findings similar to ones that were reported in a previous study.35 Furthermore, existing research has proven the connection between socioeconomic and domestic factors, such as low income,36 illiteracy, alcoholism, violent family history, lack of female autonomy and male dominance with the incidence of IPV,37 As a result, mothers who experience IPV also confront added difficulties that amplify the likelihood of child stunting and health problems before or after childbirth.36–38 These findings reiterate that IPV occurrence, directly or indirectly, is strongly linked to adverse health impacts on children born in developing countries.
The strength of these relationships may be closely linked to the social, demographic and cultural context in which IPV is observed in these descriptive studies. Various pooled analysis studies conducted in LMICs, including South Asia, have reported an association between maternal experience of physical or sexual IPV and an increased risk of child stunting.13 15 Interestingly, this link between all forms of IPV and child stunting did not appear in Pakistan, even though the prevalence of stunting among children exceeded 40%, and over one-fourth of women experienced IPV. This discrepancy might be attributed to other sociocultural and demographic factors that directly contribute to the high prevalence of both child stunting and IPV. A previous study from Pakistan reported a significant association between IPV and child stunting.39 However, the prevalence of abuse did not show a consistent trend across the countries. Notably, countries with low to medium Human Development Index (HDI) scores, such as Pakistan, Nepal and India, displayed higher rates of stunting.
It was surprising to note that IPV seemed to slightly reduce the risk of a child’s stunting in the Maldives. However, this outcome could be influenced by survivor bias in the context of a cross-sectional analysis. Despite this, the introduction of mediating variables did not notably alter the estimates of IPV’s impact on child stunting. Concerns may arise regarding the precision of proxy variables and the possible timing of events. While the examined mediators may partly explain the observed connections between IPV and child stunting and malnutrition outcomes in certain contexts, it is plausible that other unexplored pathways exist. This likelihood is particularly pronounced in the case of the Maldives. Another conceivable explanation could be associated with missing data or drop-outs, which could have affected the distribution of stunting among IPV and non-IPV groups in the Maldives. Several factors contribute to this phenomenon, including varying confounding elements, missing data or drop-out occurrences, a lower prevalence of all types of IPV and child stunting, and potential measurement errors. Moreover, it is critical to acknowledge that the DHS surveys were not explicitly designed to investigate these associations. A separate study using secondary data from 42 countries also reported a protective link between child wasting and IPV.13 This protective association could potentially stem from situations where aggressive behaviour towards the wife is followed by increased provision of food for the family due to feelings of guilt. Alternatively, it could be attributed to mothers overcompensating in terms of fulfilling the nutritional needs of their children, often referred to as a compensatory mechanism.40 41 Furthermore, it is likely that reverse causality is at play, wherein malnutrition, including child stunting, triggers aggressive behaviour in fathers owing to child neglect, ultimately leading to maternal exposure to IPV15 40; however, this reverse causality seems relatively unlikely.
The burden of IPV and physical IPV only was found to be consistent with other studies, which show higher rates of IPV and physical IPV in Pakistan, Nepal and India, where nearly one-fourth of women are exposed to IPV. The WHO reported that IPV constitutes a global public health issue, with nearly 30% of women worldwide having experienced physical and sexual violence from an intimate partner.42 Moreover, the prevalence of IPV in low-income countries, including South Asian countries, is significantly higher compared with high-income countries.4 43 Furthermore, our study demonstrated that the prevalence of all types of IPV is notably lower in the Maldives compared with other South Asian countries. According to the Global Gender Gap Report 2021, South Asian countries report the largest gender gaps that cause violence against women.44 45 It is also interesting to highlight that the gender gap is lower in Nepal and higher in the Maldives, yet the Maldives shows better performance in terms of IPV rates.
Similar trends were observed in the prevalence of child stunting in three South Asian countries such as Pakistan, Nepal and India, where over one-third of children experience stunting, and more than 1 out of 10 children are severely stunted. In comparison, the prevalence of stunting in the Maldives is lower than in other South Asian countries. While the overall stunting rate is 35% in South Asia, specific countries such as Pakistan, Afghanistan, India, Bangladesh and Nepal exhibit higher stunting rates. Notably, the stunting rate reported in our study surpasses the projected global stunting rate (20.8%) for children aged 0–59 months in 2020.46 Moreover, Sri Lanka and the Maldives report stunting rates of less than 20% in the South Asian region. Other studies have also confirmed that Sri Lanka and the Maldives have a lower prevalence of stunting than other South Asian countries.47 48
Various research from across the globe has examined the relationship between IPV and children’s nutrition status under 5 years of age.13 40 49 50 These studies have consistently identified a significant association between IPV and children’s nutritional status. However, the association between IPV and nutritional indicators such as stunting, wasting and being underweight varies across geographical locations. For example, most studies emphasise that physical and sexual violence are linked to child stunting and being underweight but not to child wasting. However, some studies indicate that the strength of the relationship between IPV and stunting varies depending on the type of violence. A recent systematic review and meta-analysis of 17 studies confirmed the significant association of IPV with child stunting and underweight but did not find an association with child wasting.20
This study does have several limitations. The dataset employed in this study is cross-sectional, which raises questions about temporality and causality—limitations inherent to such designs. Despite controlling for several potentially confounding variables, there remains a possibility of confounding due to other unidentified factors. Furthermore, residual confounding stemming from the variables included in our multivariable analysis may also persist. Cultural factors and variations in data collection techniques among countries can influence disclosure rates, potentially leading to under-reporting of violence, thereby affecting the validity of observations. While efforts were made to adjust for confounders, other concurrent influences, such as family violence (including child abuse/neglect) or household substance abuse, which may impact child outcomes, were not accounted for. Additionally, the association did not exhibit consistency within countries across various types of IPV and child stunting, including severe stunting.
Conclusion
Child stunting and IPV are growing public health issues, causing grave concern. The burden of stunted growth and IPV is high in South Asian countries, as the infliction of physical, sexual or both forms of IPV on mothers in the region is prevalent. The analysis in the study shows that maternal exposure to IPV is a potentially significant social issue influencing child healthcare in South Asian countries, especially in countries with a low to medium ‘HDI’. Our results depict that both forms of IPV, physical and sexual, either together or individually, lead to child stunting, reiterating the existing evidence of the adverse impact of IPV on child stunting. Addressing the highly prevalent issue of IPV would help reduce its detrimental impacts on child outcomes, such as their growth and development. Hence, it is concluded that effective interventions to prevent violence against women will contribute to the reduced burden of child malnutrition and subsequent stunting. Policy initiatives must be introduced to improve women’s education, awareness of IPV and decrease women’s oppression, which would lead to improved child health outcomes and reduce the incidence of child stunting. Providing comprehensive support and assistance to victims of IPV through social services should be prioritised. This support can include access to safe shelters, counselling services, legal assistance and helplines for women facing violence. Additionally, community awareness programmes and educational campaigns about IPV should be implemented to encourage reporting and seek help when needed.
Data availability statement
The DHS data is publically available on request directly from DHS website.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval was taken from the Aga Khan University Ethical Review Committee in the form of an exemption (2022-7576-23455). Dataset authorisation was acquired from the DHS. Routine consent procedures were not applied as this was secondary data analysis.
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