CLINICAL ARTICLE Intimate partner violence and its association with women's reproductive health in Pakistan Rubeena Zakar a, ⁎, Muhammad Z. Zakar a, b , Rafael Mikolajczyk c , Alexander Krämer a a Department of Public Health Medicine, School of Public Health, Bielefeld University, Bielefeld, Germany b Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan c Bremen Institute for Prevention Research and Social Medicine, Bremen University, Bremen, Germany abstract article info Article history: Received 21 July 2011 Received in revised form 26 October 2011 Accepted 13 December 2011 Keywords: Intimate partner violence Reproductive health Sexually transmitted infections Unintended pregnancies Objective: To determine the prevalence of intimate partner violence in Pakistan and its association with reproductive health outcomes. Methods: A cross-sectional survey was conducted in 8 hospitals in Lahore and Sialkot between October 2008 and January 2009. Information from randomly selected ever-married women of reproductive age was collected via a structured interview. Psychologic, physical, and sexual violence was categorized as “no” or “severe” violence. Associations between reproductive health outcomes and violence were assessed by multivariate logistic regression. Results: Among 373 women interviewed, 75.9% reported severe psychologic, 34.6% reported severe sexual, and 31.9% reported severe physical violence at least once in marital life. Women who experienced severe physical violence were more likely to have their husband's noncooperation in using contraceptives (adjusted odds ratio [AOR], 3.31; 95% confidence interval [CI], 1.93–5.68), poor prenatal care (AOR, 2.11; 95% CI, 1.23–3.69), unplanned pregnancies (AOR, 2.29; 95% CI, 1.39–3.76), and poor self-reported reproductive health (AOR, 2.95; 95% CI, 1.71–4.91) as compared with non- abused women. Similar associations existed for other types of violence. Conclusion: The results highlight the magnitude of violence and its association with reproductive health of women. Urgent action is needed to mitigate the violence and its consequential damage to health. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction The association between intimate partner violence (IPV) and reproductive health consequences has been widely reported for many high-income [1,2] and low-income [3–5] countries. Arguably, IPV may undermine reproductive health in many ways: it may create a climate of fear that makes it difficult for women to negotiate the use of contraceptives with their husbands [3,5,6] or to get proper prenatal care. The women who are victims of IPV might experience unin- tended pregnancies [2,6], abortions [3,7], and gynecologic disorders such as irregular vaginal bleeding [1,8], genital injury, dysmenorrhea [8], sexually transmitted infections [1], and sexual dysfunction [8,9]. IPV may be even more damaging in societies where women have restricted mobility, low socio-economic status, and lack the resources and autonomy to “control the damage”. Pakistan is among the countries that have high gender disparities in education, health, and labor force participation [10], and Pakistani women are the frequent victims of IPV [11]. Clinic-based small- sample studies have reported that, in Pakistan, the lifetime preva- lence of IPV ranges from 34% to 57.6% for physical violence [11–13], 43% to 97% for psychologic violence [11,14,15], and 21% to 54.5% for sexual violence [11,16]. Nonetheless, there is a lack of studies asses- sing the association of IPV and reproductive health outcomes. Thus, the aim of the present study was to investigate the prevalence and severity of IPV and its association with various dimensions of repro- ductive health in Pakistan. 2. Materials and methods The present study was a part of the dissertation project on spousal violence against women and its implications for women's health in Pakistan [17]. The hospital-based cross-sectional survey was con- ducted between October 8, 2008, and January 23, 2009, in 2 cities in Pakistan. The study participants were recruited from 8 randomly selected tertiary-care hospitals (2 private and 2 public hospitals in each city) in Lahore, the second largest city in Pakistan (population 10 million), and Sialkot (population 0.8 million). As a part of the dis- sertation [17], the study protocols were reviewed and approved by the dissertation committee of the School of Public Health, Bielefeld University, Germany. In Pakistan, the study was coordinated by the University of the Punjab. The study objectives and methodology were also reviewed and approved by a committee of academicians International Journal of Gynecology and Obstetrics 117 (2012) 10–14 ⁎ Corresponding author at: Department of Public Heath Medicine, School of Public Health, Bielefeld University, Universität Strasse 25, 33615 Bielefeld, Germany. Tel.: +49 521 106 2657; fax: +49 521 106 2987. E-mail addresses: rubeena499@hotmail.com, rubeena_ashraf.zakar@uni-bielefeld.de (R. Zakar). 0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.10.032 Contents lists available at SciVerse ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo