Background: In low-socioeconomic countries, sexual violence is the most common gender-based problem that challenges women’s daily lives and leads to adverse pregnancy outcomes.

Objectives: This study aimed to assess the prevalence of sexual violence and its associated factors among pregnant women in Mattu Town, Southwest Ethiopia.

Study Design: Community-based cross-sectional study

Methods: A simple random sampling method was employed among 414 pregnant women in Mattu Town from January 1 to 30, 2023. A face-to-face interviewer-administered structured questionnaire was used to collect the data. Binary and multivariable logistic regression analyses were performed to identify factors associated with sexual violence and are presented with adjusted odds ratios (aOR) and 95% confidence intervals (CI). The level of significance was declared at a p-value of less than 0.05.

Results: Of the 405 pregnant women included in the study, 23.46% had sexual violence (95% CI: 19.31%, 27.90%). Sexual violence was more likely among pregnant women who were married before the age of 18 (aOR:2.13; 95% CI: 1.12, 4.04), exposed to controlled behavior (aOR:8.42; 95% CI:9 4.40, 16.07), partner with secondary educational level (aOR:4.11; 95% CI:1.25, 13.59), partner daily khat use (aOR:2.79;95% CI:1.16, 6.68), and partner decision-making on household affairs (aOR:3.70; 95% CI:1.50, 9.32).

Conclusions: This study found that sexual violence among pregnant women is high. Early marriage, daily partner khat use, partner decision-making, control of behavior, and partner educational level were significantly associated factors identified among this population group.

Sexual violence, Pregnant women, Community-based, Mattu town, Southwest Ethiopia

Wedajo LF, Alemu SS, Tola MA (2023) Sexual Violence among Pregnant Women in Southwest Ethiopia: Community-Based Cross-Sectional Study Design. Med J Obstet Gynecol 11(3): 1174.

The World Health Organization (WHO) defines safe sexual practice as a state of physical, emotional, mental, and social well being related to sexuality [1]. Violence against women is defined as an attempt related to gender that result in physical, sexual, or mental harm. In addition, it is coercion or arbitrary deprivation of liberty occurring in a public or private setting among women [2]. Sexual violence is the most common gender-based problem that affects women’s daily lives. It includes any sexual act, attempts to satisfy a sexual need, or other forced sexual practices committed by any person, regardless of the relationship with the victims [3].

Pregnancy is an amazing gift of nature in a woman’s life and is accompanied by changes in physiology, anatomy, and psychology [4]. Scholars have identified that pregnancy has an impact on the sexual life of a couple owing to hormonal, emotional, physiological, and anatomical changes [5,6]. In addition, the increase in gestational age increases the couple’s stress about the possible complications of sexual intercourse [7]. The main problem regarding the sexual lives of couples in low socioeconomic countries is that they never explicitly decide on the problems that affect the expression of sexual desires and sexual behavior [1,8]. In most African countries, including Ethiopia, sexual issues are considered taboo; however, they have a negative impact on quality of life and a psychopathological impact on couples [9,10], which leads to sexual violence [11]. Different international organizations have stated that sexual violence is the most common human rights violation among women in the world [2,12].

A systematic review and meta-analysis of ten studies revealed that 31% of pregnant women worldwide suffer from sexual violence [13]. The prevalence of sexual violence ranges from 13.2% to 36.6%, which is grossly underreported, especially in developing countries [14-16]. In Ethiopia, studies conducted among pregnant women in the Tigray region and Debre Markos town revealed a prevalence of sexual violence ranging from 15.5% to 19.4% during pregnancy [16,17].

This problem can lead to prenatal depression, insomnia, anxiety, social dysfunction, eating disorders, and substance abuse, which can affect pregnancy outcome [18]. Sexual violence leads to complications such as cervical incompetence, vaginal infection, sexually transmitted disease, and increased fear of childbirth [19], as well as negative pregnancy outcomes such as miscarriage, premature rupture of membranes, placental abruption, and neonatal death [20,21].

The studies identified factors associated with sexual violence, such as socioeconomic status, maternal education level, partner education level, partner alcohol use, and unplanned pregnancy [14,16,17]. Despite previous studies on violence against women, the prevalence and associated factors for sexual violence in pregnancy are less researched and sluggish behind its reduction in Ethiopia, particularly no study done in the southwest part of Ethiopia. Therefore, this study aimed to uncover the prevalence of sexual violence and its associated factors using the population of pregnant women in Mattu Town.

Study Setting

The study was conducted in Mattu Town from January 1 to 30, 2023. Mattu Town is the administrative capital of the Iluababor Zone, 600 km from the capital city of Addis Ababa. This town has six kebele, Aba Saya, Gadisa Oda, Tabo, Kolokorma, Aba Mole, and Sor, with 42,496 households and a total population of 102,074. This town has one government referral hospital, one non-governmental hospital (Hamlin Fistula Center), one governmental health center, six health posts, and 28 private clinics. The town annually has 3,840 expected pregnancy and deliveries [22].

Study Design and Population

A community-based cross-sectional study design was used. All pregnant women in Mattu Town were the source population, while all pregnant women in Mattu Town during the data collection period were the study population.

Inclusion Criteria

All pregnant women in Mattu town were included in the study.

Exclusion Criteria

Pregnant women who lived in Mattu town for less than six months and were critically ill during data collection period were excluded from the study.

Sample Size Determination

The sample size was calculated using a single population proportion formula based on the proportion of sexual violence (19.4%) from a previous study conducted in Northwest Ethiopia [23]; based on assumptions of a 95% confidence level with 1.96 °of precision and a margin of error of 4%, as follows:

Where, n = sample size

p = proportion of previous study

za/2= degree of precision

d = margin of error

After 10% of the non-response rate was added, a final sample size of 414 was used for the purpose of the study.

Sampling Techniques

The total number of pregnant women in Mattu Town was obtained from the family folder of each kebele. After the sample was allocated to each kebele proportionally based on the size of the pregnant women in each kebele, a simple random sampling method was employed to select eligible pregnant women. Finally, with the help of the health extension workers in each kebele, a unique code was assigned to the houses of the selected women one week before the actual data collection period to facilitate data collection.

Variables of the Study

The outcome variable in this study was sexual violence. The independent variables were maternal age, occupation of the women, occupation of the male partner, maternal educational level, partner educational level, household wealth index, personal characteristics (control of behavior, decision maker of household), substance use (maternal alcohol use, male partner alcohol use, and male partner khat use), and reproductive characteristics (age at marriage, pregnancy status, history of abortion, and stillbirth or neonatal loss).

Operational Definitions and Measurement

Sexual violence: A pregnant woman who practiced sex with her husband without her interest, practiced sex due to fear of what her husband might do, or practiced an unnatural form of sex was considered the victim of the problem. Sexual violence was categorized as “yes” (coded as 1), if at least one of the question were considered to have been sexually violated during their current pregnancies and those who answer “no” (coded as 0) to any of the questions were not violated [24].

Control of behavior: was assessed by asking five questions, and women who responded “yes” to at least one of the questions were considered victims of control of behavior [24].

Pregnancy status: indicate whether the pregnancy was planned or not before conception.

The wealth index is assessed using 38 items to determine the ownership assets of the household and principal component analysis was done. Then it was classified as poor, medium, or rich [25].

Alcohol use was assessed by the history of alcohol use by the study participant or male partner in the past 30 days and classified as never used, one-two per week, two-three per month, or daily [26].

Khat use was assessed by the history of khat use by the male partner in the past 30 days and classified as never used, one-two per week, two-three per month, or daily [26].

Data Collection

A face-to-face interviewer-administered structured questionnaire was used to collect the data. The outcome variable was measured by items developed from related literature [24], that contain three items to assess sexual violence against pregnant mothers. This tool contains three items: practicing sex due to fear of her husband, practicing sex due to fear of what her husband might do, and engaging in an unnatural form of sexual intercourse with a male partner during her current pregnancy. These items were measured by “yes or no” questions. Control of behavior was measured by five questions developed from related literature [24], and the household wealth index was measured by 38 items developed from previous studies to assess the wealth status of the household [25].

Data were collected by six trained health extension workers, who were interchanged for data collection with the kebele data collector to ensure the confidentiality of information. No health extension workers were assigned to the kebeles where they lived. Data collection was supervised by three trained female public health officers. Before data collection, written informed consent was obtained after the participants were informed of the nature and advantages of the study. The interviews were held free from any person to maintain the confidentiality of the information. Women who were victims of the problem were counseled by data collectors and supervisors at the end of data collection to visit nearby health institutions.

Before data collection, the tool was translated from English to Afan Oromo, which was then translated into English. To ensure the quality of the data, a pre-test was conducted on 5% of the sample size in Bure Town. Initially, training was given to data collectors and supervisors on the questionnaires and the data collection process. Supervision was held by supervisors daily to ensure the clarity, accuracy, and consistency of the collected data on a daily basis.

Statistical Analysis

All collected data were cross-checked for completeness and consistency, cleaned, coded, and double-entered into Epi-Data 3.1 and exported to SPSS 26 for analysis. Descriptive statistics such as frequency, percentages, and summary measures were calculated, and the results were presented using narrative form and tables. Both the crude odds ratio and adjusted odds ratio with a 95% confidence interval (CI) were calculated to determine the association and strength of the association, respectively.

Variables with a p-value < 0.25 in the binary logistic regression analysis were transferred to multi-variable logistic regression to control for the effect of confounders. Lastly, in multivariable logistic regression analysis, variables with a p-value of < 0.05 were declared statistically significant factors. Model fitness was also checked using the Hosmer-Lemeshow goodness-of-fit test. A multicollinearity test was performed using the variance inflation factor and collinearity statistics, and no multicollinearity was detected. The final results are presented in tables, figures, and narrative forms.

Socio-demographic characteristics of the study participants

In this study, 405 pregnant women participated, with a response rate of 97.83 percent. The mean age and standard deviation of the study participants were 28.50 ± 5.98 SD, respectively. This study revealed that 176 (43.5%) mothers were in the 25–30 age category and 155 (38.8%) mothers were housewives. In addition, 66.9% of the participants’ partners were self-employed, while 27.9% were government employees. Regarding educational status, 11.9% and 5.2% of the study participants and their partners, respectively, had no formal education. Furthermore, 69.5% of the study participants had family sizes ranging from four to six, and 37.8% of them were classified as having poor economic status (Table 1).

Table 1:  Socio-demographic characteristics of pregnant women in Mattu town, Southwest Ethiopia, 2023

Footnote: * Tigre, Gurage, and Agnuak

Personal, Substance use, and Reproductive characteristics of study participants and their partner

Our study identified 64.7% of participants’ household decisions as being made by their partners, while only 3.7% decided jointly with their male partners. In addition, 48.6% of them faced behavioral control during their current pregnancy, and 23.7% of the study participants were married before the age of 18. This study revealed that 51.4% of pregnancies were not planned during the current pregnancy, and 18.5% and 2.7% of the study participants had a history of abortion and stillbirth, respectively. Regarding substance use behavior, 12.3% and 0.5% of the study participants had used alcohol one or two times per week and daily, respectively, in the past 30 days. Furthermore, 27.4% and 9.1% of the participants’ partners had been daily alcohol and khat users, respectively, in the past 30 days (Table 2).

Table 2: Personal, reproductive and substance use characteristics of pregnant women and their partners in Mattu town, Southwest Ethiopia, 2023

Prevalence of Sexual Violence among Pregnant women in Mattu town, Southwest Ethiopia, 2023

This study identified that 23.46% (95% CI: 19.31%, 27.90%) of the participants suffered from sexual violence. The study revealed that 66 (16.3%) pregnant women had practiced sex with their male partner without interest due to fear of their husbands. While 29 (7.2%) had practiced sex with their partner during their pregnancy due to fear of what their partner might do during their current pregnancy, 6 (1.5%) of them had practiced an unnatural form of sexual intercourse with their male partner during their current pregnancy (Figure 1).

Figure 1: Prevalence of sexual violence among pregnant women in Mattu town, Southwest Ethiopia, 2023.

Factors Associated with Sexual Violence among Pregnant women in Mattu town, Southwest Ethiopia, 2023

This study identified maternal and partner occupation, maternal and partner educational level, maternal age at marriage, pregnancy status, and control of behavior, decision maker of the household, and partner alcohol and khat use as factors significantly associated with sexual violence during pregnancy, with 95% CI at a p-value of less than 0.25 in binary logistic regression. After the effects of possible confounders were controlled by a multivariable logistic regression model, the decision maker of the household, partner educational level, partner khat use, control of behavior, and early marriage were significantly associated with sexual violence at a 95% CI and a p-value of less than 0.05.

The odds of sexual violence among pregnant women whose partner decides the household affairs by themselves was 3.7 times higher than that of women who decided independently (aOR = 3.70; 95% CI:1.50, 9.32). In addition, the odds of sexual violence among pregnant women who were exposed to controlled behavior were 8.42 times higher than their counterparts (aOR = 8.42; 95% CI: 4.40, 16.07). Furthermore, the odds of sexual violence among pregnant women whose partners achieved a secondary educational level were 4.11 times higher than those whose partners achieved a diploma or above (aOR = 4.11; 95% CI: 1.25, 13.59), and the odds of sexual violence among pregnant women whose partners used khat daily in the past 30 days were 2.79 times higher than those whose partners never used khat in the past 30 days (aOR = 2.79; 95% CI: 1.16, 6.68). The odds of sexual violence among women in early marriage women were 2.13 times higher than their counterparts (aOR = 2.13; 95% CI: 1.12, 4.08) (Table 3).

Table 3: Factors associated with sexual violence among pregnant women in Mattu town, Southwest Ethiopia, 2023

Footnote:* - significantly associated factors at p-value < 0.05; aOR: Adjusted Odds Ratios; cOR: Crude Odds Ratios, CI: Confidence Interval

Overall, in this study, nearly a quarter of the pregnant women suffered from sexual violence. We found that early marriage, partner educational level, partner khat use, household decision maker, and control of behavior were significantly associated with sexual violence (p < 0.05).

As it was identified, the prevalence of sexual violence was in line with the study conducted in Debre Markos, Ethiopia (19.8%) [23]; this might be due to the socio-demographic similarity among the study participants. However, this was higher than the findings of a study conducted in Tigray, Ethiopia (15.5%), India (13.8%), and Norway (18.4%) [27-29] . This might be due to the difference in the study setting, as the study conducted in Tigray, Ethiopia, was an institution-based cross-sectional study that might miss violated mothers. The discrepancy between the studies conducted in India and Norway might be due to differences in socio-demographic characteristics among the study participants. Furthermore, this finding was lower than that of a systematic review conducted in Iran (28%) [30], and a study conducted in the Northeast Anatolian Region (29.4%) [31]. This might be due to the difference in socio-demographic characteristics and disclosure of the problem to the data collectors among the study participants, which is culturally taboo in Ethiopia.

We found that early marriage was a significant factor associated with sexual violence during the current pregnancy, which is supported by the findings of a study conducted in Nepal [32]. This might be due to the lower educational level and understanding of their sexual health because of the discontinuation of their education for the sake of marriage at an early age. In addition, this study revealed that mothers whose partners achieved a secondary education level were more likely to be violated than those whose partners achieved a diploma or a higher level of education. This is supported by the evidence obtained from a study conducted in Sub-Saharan African countries using 18 Demographic Health Survey Data [33]. This might be because partners who achieved a higher level of education had a better understanding of the sexual rights of their wives than those who achieved a lower level of education. Furthermore, those partners who achieved a lower level of education might not pay attention to the interests of their wives during pregnancy, as hormonal and physiological changes during pregnancy may affect women’s quality of sexual health and lead to a decrease in sexual desire among pregnant women [34].

Women whose partners were daily khat users were more prone to sexual violence than those whose partners had never used it. This is supported by evidence obtained from a study conducted in the Jimma Zone, Southwest Ethiopia [35]. This might be because khat users might not pay attention to the sexual interests and reproductive health of their wives because of the substantial effects of the khat. In addition, those partners might listen only to their sexual interests and emotions rather than their wives [36].

Pregnant women whose partners decided their household affairs by themselves were more likely to face sexual violence than those whose partners decided by them. This is supported by evidence obtained from the Awi Zone, Ethiopia, and Southwest Ethiopia [37,38]. This might be the case with those partners who decide on everything in the household affairs, dominate the power, and impose their power on their wives, which might lead to sexual violence among women with such husbands. Such partners may focus on their own interests and make decisions that worsen sexual violence during pregnancy. Similarly, women whose partners controlled their wives’ behavior were more likely to face sexual violence during pregnancy than their counterparts. This is supported by evidence obtained from Eastern Ethiopia [39]. This might be the case for women whose partners control their behavior might suspect their wives or feel jealous, as there might be a change in the sexual interest of women during pregnancy due to the hormonal and physiological effects of pregnancy on their quality of sexual health, and they might show a change in sexual activity and performance during pregnancy.

Strength and Limitation of the study

The strength of this study is that it was a community-based study, which might ease the uncovering of sexually violated pregnant women at the community level. As it is a sensitive issue, it might be prone to social desirability bias, which leads to an underestimation of sexual violence in this population category.

In general, our study revealed that the prevalence of sexual violence during pregnancy is relatively high. We found that early marriage, partner educational level, household decision maker, partner khat consumption, and partner control of behavior were significantly associated with sexual violence in this study setting. It is better to improve women’s decision-making power in their sexual health and life through community education and mass media. In addition, the identification of substance user partners and counseling on the health of their wives might be important to reduce the problem. Furthermore, screenings of pregnant women on sexual violence by community health extension workers and health professionals are of paramount importance in overcoming this problem. Finally, it would be better if it was supported by qualitative research.

First, our deepest gratitude is for our study participants’ kindness and valuable information for this research. We also thank our data collectors and supervisors for their valuable contributions. Finally, we would like to thank Mattu University College of Health Sciences for providing ethical clearance and the Mattu Town Health Department for providing a letter of request to carry out the study.

Authors’ Contributions

Lema Fikadu Wedajo (LFW) conceived of the study. Lema Fikadu Wedajo (LFW), SSA, and MAT participated in the proposal development, tool development, and data collection process. Lema Fikadu Wedajo (LFW) analyzed the study and wrote the original draft of the manuscript. All authors revised the final version of the manuscript and approved it for publication.

Availability of Data and Materials

The data used for this study are available upon reasonable request from the corresponding author at any time, if required (e-mail: lemafika2014@gmail.com).

Ethical Approval

Ethical clearance was obtained from the Mattu University Institutional Research Review Committee with reference number “MEU/CHS/RERC/091/23,” and letters of permission were obtained from the Mattu town Health Department. All methods were performed in accordance with the principles of the Helsinki Declaration. The respondent’s name was not used by the questioners, except as a unique code for the purpose of communication, and the collected data were stored safely.

Informed Consent

Written informed consent was obtained from each participant after they understood the nature and benefits of the study.

1. Ga??zka I, Drosdzol-Cop A, Naworska B, Czajkowska M and SkrzypulecPlinta V. Changes in the sexual function during pregnancy. J Sex Med. 2015; 12: 445-454.

2. WHO G. Violence against women Prevalence Estimates, 2018. Global, regional and national prevalence estimates for intimate partner violence against women and global and regional prevalence estimates for non-partner sexual violence against women. 2021.

3. World Health organization Un. Violence against women. 2022.

4. Costantine M. Physiologic and pharmacokinetic changes in pregnancy. Front Pharmacol. 2014; 5.

5. Bostani Khalesi Z, Ghanbari Khanghah A. Perception and experience of married women of reproductive age about the importance of sexual health education: A content analysis study. Iranian J Obstetr Gynecol Infertility. 2015; 18: 7-17.

6. Khalesi ZB, Bokaie M, Attari SM. Effect of pregnancy on sexual function of couples. Afr Health Sci. 2018; 18: 227-234.

7. Afshar M, Mohammad-Alizadeh-Charandabi S, Merghti-Khoei ES and Yavarikia P. The effect of sex education on the sexual function of women in the first half of pregnancy: a randomized controlled trial. J Caring Sci. 2012; 1: 173-181.

8. Corbacioglu A, Bakir VL, Akbayir O, Cilesiz Goksedef BP, Akca A. The role of pregnancy awareness on female sexual function in early gestation. J Sexual Med. 2012; 9: 1897-1903.

9. Bokaie M, Khalesi ZB and Yasini-Ardekani SM. Diagnosis and treatment of unconsummated marriage in an Iranian couple. Afr Health Sci. 2017; 17: 632-636.

10. Jawed-Wessel S, Herbenick D, Schick V, Fortenberry JD, Cattelona G and Reece M. Development and Validation of the Maternal and Partner Sex During Pregnancy Scales. J Sex Marital Ther. 2016; 42: 681-701.

11. Mallory AB, Stanton AM, Handy AB. Couples’ Sexual Communication and Dimensions of Sexual Function: A Meta-Analysis. J Sex Res. 2019; 56: 882-898.

12. UNICEF. Gender-based violence in emergencies. 2022.

13. Shen X, Dong H, Jiang H, Cao Hu, Dowling R, Feng J, et al. The global prevalence of sexual violence against pregnant women: a systematic review and meta-analysis. Women Health. 2022; 62: 37-45.

14. Stamatakis CE, Sumner SA, Massetti G, Kress H, Basile KC, Marcelin LH, et al. Sexual Violence Prevalence and Related Pregnancy Among Girls and Young Women: A Multicountry Analysis. J Interpers Violence. 2022; 37: NP2428–NP2441.

15. Sen S, Bolsoy N. Violence against women: prevalence and risk factors in Turkish sample. BMC Women’s Health. 2017; 17: 100.

16. Abegaz MY, Muche HA, Aynalem GL, Anteneh TA, Tibebu NS, Gedef GM, et al. Prevalence of sexual violence and associated factors among women attending antenatal care in Debre Markos at public health institutions in north-west Ethiopia, 2021. Front Glob Women’s Health. 2023; 4: 1009272.

17. Adhena G, Oljira L. Sexual and psychological violence among pregnant women in tigray. Ethiopia Am J Heal Res. 2020; 8: 96.

18. Wong FY, Huang ZJ, DiGangi JA, Thompson EE, Smith BD. Gender differences in intimate partner violence on substance abuse, sexual risks, and depression among a sample of South Africans in Cape Town, South Africa. AIDS Educ Prev. 2008; 20: 56-64.

19. Gisladottir A, Luque-Fernandez MA, Harlow BL, Jonsdottir E, Aspelund T, Houksdottir A, et al. Obstetric Outcomes of Mothers Previously Exposed to Sexual Violence. PLoS One. 2016; 11: e0150726.

20. Williams H, Foster D, Watts P. Perinatal domestic abuse: Midwives making a difference through effective public health practice. British J Midwifery. 2013; 21: 852-858.

21. Belay HG, Debebe GA, Ayele AD, Kassa BG, Mihretie GN, Bezabih LM, et al. Intimate partner violence during pregnancy and adverse birth outcomes in Ethiopia: A systematic review and meta-analysis. PLoS One. 2022; 17: e0275836.

22. Town M. Mattu town adminstrative and health deparment offices 2023.

23. Sitot A. Prevalence of sexual violence and associated factors among women attending antenatal care at Debre Markos town at public health institutions, North-west Ethiopia, 2021. Frontiers in Global Women’s Health. 2021; 4: 8.

24. Lencha B, Ameya G, Baresa G, Minda Z, Ganfure G. Intimate partner violence and its associated factors among pregnant women in Bale Zone, Southeast Ethiopia: A cross-sectional study. PloS one. 2019; 14: e0214962.

25. Aychew EW, Bekele YA, Ayele AD, Dessie AM and Dagnew GW. Utilization of long-acting contraceptive methods and associated factors among married women in Farta Woreda, Northwest Ethiopia: a community-based mixed method study. BMC Women’s Health. 2022; 22: 533.

26. Dufera F, Kebira JY, Gobena T, Assefa N. Lifetime prevalence of sexual violence and its associated factors among high school female students in Jarso District, Oromia Region, Eastern Ethiopia. Int J Reprod Med. 2021; 2021: 1821579.

27. Adhena G, Oljira L. Sexual and psychological violence among pregnant women in Tigray, Ethiopia. Am J Health Res. 2020; 8: 96-101.

28. Bramhankar M, Reshmi R. Spousal violence against women and its consequences on pregnancy outcomes and reproductive health of women in India. BMC Women’s Health. 2021; 21: 1-9.

29. Henriksen L, Schei B, Vangen S and Lukasse M. Sexual violence and neonatal outcomes: a Norwegian population-based cohort study. BMJ Open. 2014; 4: e005935.

30. Bazyar J, Safarpour H, Daliri S, Karimi A, Keykaleh MS, Bazyar M. The prevalence of sexual violence during pregnancy in Iran and the world: a ‎systematic review and meta-analysis. J Inj Violence Res. 2018; 10: 63-74

31. Tunc EB, C?lg?n H, Tunc S, Oner C and Catak B. Social determinants of sexual violence against pregnant women. Clinical Epidemiol Global Health. 2021; 10: 100706.

32. Pandey S. Physical or sexual violence against women of childbearing age within marriage in Nepal: Prevalence, causes, and prevention strategies. International Social Work. 2016; 59: 803-820.

33. Ahinkorah BO, Dickson KS and Seidu AA. Women decision-making capacity and intimate partner violence among women in sub-Saharan Africa. Arch Public Health. 2018; 76: 1-10.

34. Alizadeh S, Riazi H, Majd HA, Ozgoli G. The effect of sexual health education on sexual activity, sexual quality of life, and sexual violence in pregnancy: a prospective randomized controlled trial. BMC Pregnancy and Childbirth. 2021; 21: 1-11.

35. Gadisa TB, Kitaba KA, Negesa MG. Prevalence and factors associated with domestic violence against married women in Mana District, Jimma zone, Southwest Ethiopia: A community-Based Cross-Sectional study. Int J Africa Nursing Sci. 2022; 17: 100480.

36. Sharma V, Papaefstathiou S, Tewolde S, Amobi A, Deyessa N, Relyea B, et al. Khat use and intimate partner violence in a refugee population: a qualitative study in Dollo Ado, Ethiopia. BMC Public Health. 2020; 20: 1-10.

37. Semahegn A, Belachew T, Abdulahi M. Domestic violence and its predictors among married women in reproductive age in Fagitalekoma Woreda, Awi zone, Amhara regional state, North Western Ethiopia. Reproductive Health. 2013; 10: 1-9.

38. Fetene G, Alie MS, Girma D, Negesse Y. Prevalence and its predictors of intimate partner violence against pregnant women amid COVID-19 pandemic in Southwest Ethiopia, 2021: A cross-sectional study. SAGE open medicine. 2022; 10: 20503121221079317.

39. Musa A, Chojenta C, Loxton D. High rate of partner violence during pregnancy in eastern Ethiopia: findings from a facility-based study. PLoS One. 2020; 15: e0233907.