Beyond Healthcare Access: How Intimate Partner Violence Undermines Uganda's Progress Toward Universal Maternal Health Coverage Through Reduced Maternal Health Service Utilization

Beyond Healthcare Access: How Intimate Partner Violence Undermines Uganda's Progress Toward Universal Maternal Health Coverage Through Reduced Maternal Health Service Utilization | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond Healthcare Access: How Intimate Partner Violence Undermines Uganda's Progress Toward Universal Maternal Health Coverage Through Reduced Maternal Health Service Utilization Christine Nalwadda, Sarah Nabukeera, Timothy Kasule, Juliet Mujuni Kwabaho, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8584432/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Evidence suggests that Intimate Partner Violence (IPV) is associated with reduced use of maternal health services (MHS), including ANC, institutional deliveries, and use of modern contraception. The effects of IPV on MHS work through mechanisms such as psychological barriers, alongside restricted decision-making and movement related to financial dependence, and fear of further abuse. We assessed trends in IPV and its effects on accessing healthcare, and two maternal health services (ANC and institutional delivery) among women of reproductive age (15–49 years) in four nationally representative surveys in Uganda. Methods In this study, we conducted a cross-sectional analysis of secondary data, utilizing information from four Uganda Demographic and Health Surveys (UDHS) that were carried out in 2006, 2011, 2016, and 2022. The UDHS uses a multistage stratified sampling methodology to select households from both urban and rural areas across regions in Uganda. Women between the ages of 15 and 49 years who were either residents or visitors in these households were eligible for interviews. Data for this analysis are drawn from the domestic violence module that generates information on spousal/intimate partners violence among ever-married women. Both exploratory and inferential data analyses were conducted to generate descriptive statistics for key variables, and a modified Poisson regression model to provide evidence for the association between maternal health services and IPV using prevalence ratios (PRs) with 95% confidence intervals as measures of association. Analyses were weighted and accounted for a multi-stage cluster design, conducted using svyset command in STATA version 18. Results Trends in the women experiencing intimate partner violence (IPV) in the 12 months prior to the survey, and women reporting serious problems accessing healthcare (SPAHC) varied over the four UDHS. Overall, SPAHC dropped from 83.1% in 2006 to 60% in 2022, p-for-trend < 0.000. Similarly, IPV declined in the same period, dropping from 52.6% in 2006 to 39.2% in 2016, but increased to 45% in 2022. The overall pooled effect of IPV on SPAHC across the four DHS was about 8% higher among the ever-married women reporting IPV. The effects of IPV the two maternal health service; women’s place of delivery of the last birth in the past 5 years, comparing delivery at a public/ private health facility versus delivery at home, and timely (0–3 months) first ANC visit for the last birth tended to lower when women experienced IPV. Conclusion The study emphasizes the links between social determinants of health, serious problems in accessing healthcare and maternal services, and IPV as a major risk factor. Policymakers should enhance strategies to prevent IPV, which negatively impacts women's health and pregnancies, focusing on disadvantaged women, especially those in rural, low-education, and poorer communities. Intimate Partner Violence Antenatal Care Maternal Health Services Figures Figure 1 Figure 2 Figure 3 Background Maternal mortality remains a significant public health issue across the globe. The World Health Organization (WHO) reports that over 303,000 women died worldwide because of complications related to pregnancy and childbirth. To lower maternal mortality, the WHO recommends that every expectant mother have access to maternal health services (MHS) like antenatal care and professional assistance during delivery [ 1 , 2 ]. ANC involves support from healthcare providers to ensure the health of both mother and baby during pregnancy, to skilled delivery care provided by trained professionals during delivery and childbirth [ 2 , 3 ]. Numerous factors affect access to MHS, including maternal age, education, marital status, and socioeconomic status. Additional key factors are the quality of services as determined by proximity to healthcare facilities, duration of waiting times, views on health workers, as well as community and cultural beliefs [ 7 – 11 ]. Globally, intimate partner violence (IPV) is recognized as a major determinant of poor maternal health outcomes [ 6 – 9 , 14 ]. IPV is a pattern of behaviour where one partner tries to gain or maintain power and control over another in a relationship, which may be exhibited through physical, sexual, emotional, economic, and psychological abuse or threats. IPV has been reported to affect utilization of MHS [ 10 ], which either directly or indirectly exposes women to maternal health challenges, including deaths [ 4 – 6 ]. A worldwide meta-analysis revealed that women who faced IPV had 25% reduced chances of receiving sufficient ANC and 20% reduced chances of using skilled delivery services compared to women who did not face IPV [ 7 ]. Relatedly, a distinct systematic review on women's health indicated that experiencing IPV decreased the likelihood of utilizing adequate ANC by half, while physical IPV lowered the odds for receiving four or more visits by approximately 34% [ 8 , 9 ]. A 2016 national survey in Uganda found that about 60.8% of women experienced IPV in the past 12 months. There was a statistically significant difference between women who experienced any form of IPV and those who did not experience any IPV. Women who faced IPV attended an average of 3.64 ANC visits, compared to 3.82 visits for those without IPV [ 10 ]. Another study indicated a significant link between IPV and fewer ANC visits, even after considering socio-economic factors, and implied that women experiencing IPV are less likely to meet the recommended ANC visit guidelines [ 10 , 11 ]. IPV reportedly reduces MHS utilization through various mechanisms, including psychological and emotional barriers, such as fear, stress and depression, restricted decision making and movement due to lack of financial independence by the woman, as well as fear for further abuse by the partner [ 6 ]. Although the proportion of women aged 15–49 in Uganda who received ANC from a skilled provider increased from 97% in 2016 to 99% in 2022, there were inequities in ANC service utilization across the social determinants of health, including region, rural-urban, education level, and wealth quintile [ 12 , 13 ]. Additionally, studies have also shown that IPV is prevalent in Uganda, particularly among expectant mothers, and is strongly associated with reduced attendance at ANC and institutional deliveries, increasing the likelihood of negative outcomes for both mothers and infants [ 10 , 11 ]. Nine percent of women who had ever been pregnant had experienced physical violence during one or more pregnancies. Fifty-eight percent of ever-married women had experienced a certain form of physical, sexual, or psychological abuse; this was more among the rural women, the less educated, and with regional variations [ 12 ]. These disparities hinder the achievement of universal health coverage for all pregnant women in the country, as they disproportionately affect specific groups, ultimately undermining Uganda’s goals of achieving comprehensive maternal and child health coverage. While national recommendations support regular screening of pregnant women for IPV, various structural, cultural, and training obstacles hinder effective implementation. Besides, the extent to which IPV influences MHS use and obstructs Uganda's advancement toward universal maternal health coverage is still not well understood. This study examined how IPV undermines Uganda's progress toward universal maternal health coverage through reduced MHS, with a focus on ANC and institutional delivery service utilization. We assessed trends in IPV and its effects on accessing healthcare, and two maternal health services (ANC and Institutional delivery) among women of reproductive age (15–49 years) in four nationally representative surveys in UgandaThe findings highlight a critical window of opportunity for public health interventions to address IPV among the affected groups to achieve UHC and meet Sustainable Development Goal 3 (SDG3) for Uganda and beyond. Methods Study design and Study setting Data for this cross-sectional secondary data analysis were obtained from the four most recent Uganda Demographic and Health Surveys (UDHS) conducted in 2006, 2011, 2016 and 2022, and are publicly available and accessible upon request on the Demographic Health Survey (DHS) Program and the Uganda Bureau of Statistics (UBOS) websites. UBOS, in collaboration Ministry of Health (MoH) and other national stakeholders and international development partners and with the International Classification of Functioning, Disability and Health (ICF), conduct the surveys. A nationally or sub-nationally representative sample of data from households and women on several indicators, including a module on domestic violence, in addition to key maternal healthcare services and access to healthcare, is collected. In Uganda, the UDHS surveys for 2006 and 2011 had the country stratified into 10 sub-regions, while 2016 and 2022 were further stratified into 15 sub-regions defined by the UBOS. These include Acholi, Ankole, Bukedi, Bugisu, Bunyoro, Busoga, Kampala, Karamoja, Kigezi, Lango, North Buganda, South Buganda, Tooro, Teso, and West Nile [ 12 , 13 , 15 , 16 ]. Sample size and sampling The DHS is a complex survey design that utilizes a multistage stratified sampling to select households. The country is divided into regions, and the population within each region is stratified into urban and rural areas. Clusters or enumeration areas (EAs) within each stratified area are randomly selected, and these form the primary sampling units (PSUs). The PSU selection is based on a probability proportional to size, which considers the number of households. Through the two-stage cluster sampling approach, selection of the clusters/EAs was the first stage, while in the second stage, households in each PSU were randomly selected following the listing of all households within the PSU. A fixed number of households within each PSU is randomly selected using systematic sampling. A total of 15 regions were considered in the 2016 and 2022 UDHS, while the 2006 and 2011 surveys had 10 regions [ 12 , 13 , 15 , 16 ]. To simplify the household listing process, larger EAs (those with more than 300 households) are segmented. From these segments, only one is selected for the survey, using a probability proportional to the size of the segment, and the household listing is conducted solely in the chosen segment. Therefore, a UDHS cluster can either be an EA or a segment of an EA [ 12 , 13 , 15 , 16 ]. In total, a representative sample of 9,864 households was selected for the 2006 UDHS, 10,086 households for 2011, 20,880 households for 2016, and 22,907 for 2022. For this analysis, we considered ever-married women (currently/in union/living with a partner as if married, or formerly married) as per the domestic violence model that focused on IPV in the past 12 months prior to the survey Study Population All women aged 15–49 years who were either permanent residents of the selected households or visitors who stayed in the household the night before the survey were eligible to be interviewed [ 12 , 13 , 15 , 16 ]. This analysis only considered ever-married women (currently/in union/living with a partner as if married or formerly married) as per the domestic violence module. Note also that ever-married women are women who self-report as being married, divorced, separated, or widowed, or living with or having ever lived with a man as if married. Thus, a “partner” is a man with whom the respondent lives or lived as if married. A previous husband/partner is a husband/partner other than the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women [ 12 , 13 , 15 , 16 ]. Data Collection Four questionnaires are used to collect data in the UDHS, and among these are the Household Questionnaire and the Women’s Questionnaire. The questionnaires, based on The DHS Program’s model questionnaires, are adapted to reflect the population and health issues relevant to Uganda. In addition, information on the survey fieldworkers was collected through a self-administered Fieldworker Questionnaire. After the preparation of the questionnaires in English, the questionnaires were then translated into eight major languages: Ateso, Ngakarimojong, Luganda, Lugbara, Luo, Runyankole-Rukiga, Runyoro-Rutooro, and Lusoga. The Household Women’s quetionnaire is programmed into tablet computers to facilitate computer-assisted personal interviewing (CAPI) for data collection purposes, with the capability to choose any of the eight languages for each questionnaire [ 12 , 13 , 15 , 16 ]. Data on domestic violence in DHS surveys comes from an optional module of questions, and indicators are available for some, but not all, countries, and for only one randomly selected woman per household among all eligible women in the household. This DHS Program approach is in accordance with the WHO guidelines “Putting Women First: Ethical and Safety Recommendations for Research on Domestic Violence against Women”, World Health Organization, 2001. Therefore, the number of women for the domestic violence module will always be less than the number of women selected for the complete DHS individual interview. Questions largely ask about violence perpetrated by the current husband/partner for women who are currently married and the most recent husband/partner for women who are currently divorced, separated or widowed. Measures The analysis was focused on ever-married women (currently/in union/living with a partner as if married or formerly married) because IPV were only captured in relation to a current or most recent husband/partner for women who are divorced/separated. The primary outcome for this analysis was serious problems accessing healthcare when sick, and the secondary outcome was maternal health services, defined as the place of delivery of the most recent birth in the 5 years preceding the survey. 1). Serious problems accessing health care for themselves when they are sick, and these included four key items, i) getting permission to go for treatment, ii) getting money for treatment, iii) distance to the health facility and iv) not wanting to go alone. A composite measure, serious problems with access to healthcare (SPAHC), was constructed as the primary outcome when women reported at least one problem accessing health care and compared to not reporting any of these four items. 2). For the secondary outcomes, we constructed i) a place of delivery variable and grouped responses into public or private health facility, compared to at home or another place not a health facility for the last birth within the last 5-years of the survey; ii) timely attendance of the first antenatal care visit of the last birth that occurred within the last 2 years before the survey; a women was assigned timely ANC-1 when she attended in the first trimester (0–3 months) of the last birth within 2 years. The key exposure variable was IPV in the 12 months preceding the survey based on the three experiences of violence, a) Experienced spousal/intimate partner sexual violence in the 12 months preceding the survey by their current or most recent husbands/partners used the following items/questions i) ever been physically forced into unwanted sex by husband/partner, ii) ever been forced into other unwanted sexual acts by husband/partner, iii) ever been physically forced to perform sexual acts respondent didn't want to. b)Experienced spousal/intimate partner physical violence in the 12 months preceding the survey by their current or most recent husbands/partners had the following items/questions i) ever been pushed, shook or had something thrown by husband/partner, ii) ever been slapped by husband/partner, iii) ever been punched with fist or hit by something harmful by husband/partner, iv) ever been kicked or dragged by husband/partner, v) ever been strangled or burnt by husband/partner, vi) ever been threatened with knife/gun or other weapon by husband/partner, vii) ever clinically significant (CS) physical violence by husband/partner, viii) Ever had an arm twisted or hair pulled by husband/partner? c) Experienced spousal/intimate partner emotional violence in the 12 months preceding the survey by their current or most recent husbands/partners, had the following items/questions: i) ever been humiliated by husband/partner, ii) ever been threatened with harm by husband/partner, iii) ever been insulted or made to feel bad by husband/partner. For all three experiences, physical, sexual and emotional, women who responded often or sometimes to any of the items/questions were coded as “Yes” to reflect experience in the 12 months, while those with responses of never or yes but not within 12 months were coded as “No”. A composite spousal/intimate partner violence (IPV) was constructed and defined as yes-experience any of the 3-violences coded as “1” or “0”, if none of the three-violences were coded as yes. Potential confounder variables considered for this analysis included, women age in completed years at time of survey categorized as 15–19, 20–24, 25–34, and 35–49 years ; ever-married status ( currently married/Living together as if married/Divorced or separated ); Residence categorized as Urban and Rural ; Education, the highest level of education attained by the woman categorized as None, Primary, Post primary (Secondary and Tertiar y ) ; current pregnancy status (not pregnant, pregnant-wanted, pregnant unwanted at time) , total number of children ever-born (none, 1–3, 4–7, 8+) , working status past 12 months (not worked, worked past 12 months but not at time of survey, working currently/on leave ) and wealth index ( poorest, poor, middle, rich richest ), The wealth-index is based on measures by ownership/possession of household assets (Communication: cell or landline phone, computer, radio, TV; Transport: bicycle, motorcycle, car; Source of power: electricity, generator, solar, and materials for building/construction, ownership of the home, indoor bathroom and access to running water [ 12 , 13 , 15 , 16 ]. Data Management We merged all four datasets prior to the analysis, each with appropriate variables common across the four surveys into one dataset, after examining that all the key variables, outcome and explanatory, for this analysis were defined and labelled the same. The complex survey design variables were also maintained, including strata, clusters, and the weight variable, to enable accounting for the complex design during the analyses. For this analysis, the domestic violence weight variable, d005, was used as the guideline (Croft, Trevor N., Aileen M. J. Marshall, Courtney K. Allen, et al. 2018. Guide to DHS Statistics. Rockville, Maryland, USA: ICF). Data Analysis Data was analyzed using Stata version 18. Exploratory data analysis was conducted to generate descriptive statistics for all the key variables. Percentages for categorical variables and mean or medians with corresponding standard deviations (SD) or inter-quartile range (IQR) were obtained for the socio-economic, demographic and health variables, as well as for the primary, secondary outcome, and key exposure variable spousal/intimate partner violence variables. Frequencies for the variables were presented as unweighted, while means and proportions were weighted. We determined the trends in primary, secondary outcomes and the IPV over the four surveys. The percentage distribution of these variables was analyzed for linear chi-square for trends across the four UDHS survey periods using the trend command. We determined the association between IPV and the primary (serious problem accessing healthcare when sick) and secondary (place of delivery of last birth) outcomes. The outcomes were binary, and we therefore used a “modified” Poisson regression model via a generalized linear model (GLM) with Poisson family and log link was conducted to provide the prevalence ratios (PRs) as a measure of association. Prevalence ratios had corresponding 95% confidence intervals. The effects of the IPV on serious problems accessing healthcare across the four DHS were pooled to provide a single measure of effect for the 12 months prior to each survey. The pooled effects were analyzed through meta-analysis using the two-stage approach, where regression coefficients and standard errors (SE) were pooled. In a sub-analysis, we also considered each of the serious problem items, permission to go for treatment, needed money for treatment, distance to health facility, and not wanting to go alone, as outcomes. We also conducted an equity analysis to determine disparity in serious problems accessing healthcare by women's health status, comparing those experiencing SIPV to those who did not report. We used concentration curves and Errygen concentration indices. All analyses were weighted and accounted for a multi-stage cluster design achieved via the survey set (svyset) command in STATA software version 18. Ethics Three protective measures were integrated into the UDHS questionnaires, adhering to the ethical and safety standards established by the World Health Organization for research on domestic violence (WHO, 2001). Questions concerning violence were directed to only one eligible individual within each household. Among a selection of three households, one was specifically selected for a violence interview with a female respondent [ 12 , 13 , 15 , 16 ]. From the last two homes, one was pre-selected for a violence interview featuring a male participant. In cases where there are multiple women in a household, the participant for this section was randomly picked utilizing a specifically designed, straightforward selection technique (based on the ‘Kish Grid’) [ 17 ], which was included in the Household Questionnaire. Interviewing just one individual per household with the violence module ensures that the chosen respondent feels assured that others in the household will not discuss the types of questions posed to the selected individual. [ 12 , 13 , 15 , 16 ]. Informed consent from the respondent for the survey was obtained at the beginning of the individual interview. Additionally, prior to the violence section, respondents were presented with a statement that highlighted the sensitivity of the upcoming questions and assured them that their responses would remain confidential. The violence module was conducted only if privacy could be guaranteed. If privacy could not be ensured, the interviewer was instructed to skip this module, thank the respondent, and conclude the interview. In cases where a translator was needed, respondents were not asked questions from the violence module to protect their privacy. [ 12 , 13 , 15 , 16 ]. Results Trends in the women experiencing intimate partner violence (IPV) in the 12 months prior to the survey, and women reporting serious problems accessing healthcare (SPAHC), varied over the four UDHS. Overall, SPAHC in at least one specified problem dropped from 83.1% in 2006 to 60% in 2022, p-for-trend < 0.0001. Individually all the four specified problems declined but with an increase in the last survey in 2022 for i) getting permission to go (8.8% in 2006 to 5.12% in 2016, and to 7.4% in 2022), ii) need money for treatment (68% in 2006 to 46.4% in 2016, and to 53% in 2022), while the last two steadily declined iii) distance to health facility ( 60% in 2006 to 36.7% in 2022, p-for-trend < 0.0001) and iv) not wanting to go alone (24.6% in 2006 to 12.4% in 2022 p-for-trend < 0.0001). Getting permission to go to the least reported serious problem towards accessing healthcare, while the money needed for treatment was the most reported serious problem. Also, SIPV declined across the four DHS with women reporting at least one of the three specific violence acts dropping from 52.6% in 2006 to 39.2% in 2016, then back up to 45% in 2022. Sexual violence steadily declined from 23.5% in 2006 to 11.8% in 2022, p-for-trend < 0.0001, while physical and emotional violence declined up to 2016, but both experienced an increase in 2022. Sexual violence was the least reported, followed by physical, while emotional was the most mentioned act of violence, Table 1 . Table 1 Serious problems accessing healthcare and Intimate Partner Violence (IPV) among ever-married women across the four UDHS DHS year 2006 2011 2016 2022 p-for-trends Ever-married women (15-49years): weighted 1,598 1,588 6,879 824 Serious problems with accessing healthcare Any of the 4 problems 83.2 66.7 60.5 60.0 < 0.0001 Specific serious problem mentioned i) Permission to go for treatment 8.8 5.95 5.1 7.4 < 0.0001 ii) Need money for treatment 68.4 51.7 46.4 53.0 < 0.0001 iii) Distance to health facility 60.0 45.1 39.6 36.7 < 0.0001 iv) Not wanting to go alone 24.6 23.2 21.8 12.4 < 0.0001 Intimate partner violence in the past 12 months Any of the 3 forms of violence 52.6 42.0 39.2 45.1 < 0.0001 Specific violence mentioned i) Physical 33.4 23.7 22.3 26.4 < 0.0001 ii) Sexual 23.5 19.1 15.9 11.8 < 0.0001 iii) Emotional 37.0 31.0 29.3 34.4 < 0.0001 The effect of SIPV on serious problems in accessing healthcare among the ever-married women was minimal, ranging from 4% in 2006 to 14% in 2016, and was statistically significant in 2011, adj.PR = 1.09(1.002, 1.191) and in 2016, adj.PR = 1.14(1.093, 1.198). Pooled analysis of coefficients of SIPV resulted in 8% higher risk of serious problems accessing healthcare for women who experienced SIPV in the 12 months prior to the survey, pooled adj.PR = 1.08(1.02, 1.15), Fig. 1 . In the analysis for each of the four individual serious problems of accessing healthcare as an outcome, permission to go for treatment had the highest effects of IPV with adj.PR = 1.52(0.805, 2.872) in 2022 to adj.PR = 2.61 (1.478, 4.614) in 2011, and this was followed by not wanting to go alone, adj.PR = 1.16(0.915, 1.465) in 2011 to adj.PR = 1.66(1.096, 2.517) in 2022, Table 2. Table 2: Effects of IPV in the past 12 months on the problem of accessing healthcare among ever-married women Problem accessing healthcare Experienced any of the 3 IPV-12-month vs none Any of the 4 problems Permission to go for treatment Money needed for treatment Distance to health facility Not wanting to go alone DHS year (number of observations) *Adj.PR(95%CI) *Adj.PR(95%CI) *Adj.PR(95%CI) *Adj.PR(95%CI) *Adj.PR(95%CI) DHS2006 (1746) 1.04 (0.994, 1.096) 1.81 (1.240,2.641) 1.07 (1.003,1.146) 1.03 (0.937,1.142) 1.19 (0.961,1.464) DHS2011 (1705) 1.09 (1.002, 1.191) 2.61 (1.478,4.614) 1.13 (0.994,1.288) 1.03 (0.908,1.177) 1.16 (0.915,1.465) DHS2016 (7536) 1.14 (1.093,1.198) 1.78 (1.349,2.349) 1.18 (1.111, 1.254) 1.05 (0.977,1.124) 1.31 (1.181,1.458) DHS2022 (786) 1.05 (0.925,1.190) 1.52 (0.805,2.872) 1.06 (0.915,1.234) 1.13 (0.937,1.361) 1.66 (1.096,2.517) Note: * adjusted for: Age, marital status (current or formerly married), education, wealth quintile. Working status past 12 months, residence, total children ever born, current pregnancy status, To further understand the effect of IPV on serious problems in accessing healthcare, we assess for disparity in serious problems accessing healthcare by increasing women's wealth status, stratified by experience of IPV in the 12 months prior to the survey. Overall, women in the lower wealth quintile were disproportionately more likely to have serious problems accessing healthcare. However, this disparity was lower in women who did not experience IPV, apart from the 2006 survey, where the disparity was largely similar (Coindex − 0.1956 compared to -0.2068), Fig. 2 . Factors associated with a lower risk of serious problems accessing healthcare across all the surveys included were higher wealth status, with nearly a 20% or more reduced risk for women in the middle-to richest quintile relative to the poorest. Similarly, a reduction in the risk of problems accessing healthcare was observed in women reporting being currently married compared to the formerly married women, ranging from 8% in 2006 to 13% in 2016, but not in 2022, adj.PR = 1.01(0.82, 1.25). In the pooled analysis, being currently married was associated with a lower risk of serious problems accessing healthcare, pooled adj.PR = 0.91(0.86, 0.98). Post-primary relative to no education also had a lower risk, but these were not statistically significant. Women with unintended pregnancy compared to non-pregnant and those with 4 or children ever-born (CEB) reported a higher risk of serious problems accessing healthcare, but the association was statistically significant mainly in the 2006 survey, Table 3 . Table 3 IPV (Physical, Sexual and Emotional) experience in the past 12 months by partner among ever-married women and serious problem access to healthcare (permission to go/money needed for treatment/distance to facility/not wanting to go alone ). Outcome: Problems with accessing healthcare Main Exposure-IPV Adj.PR p-value Adj.PR p-value Adj.PR p-value Adj.PR p-value Experienced any of the 3 IPV past 12 months No 1.00 1.00 1.00 1.00 Yes 1.04 [0.99–1.10] 0.087 1.09 [1.00-1.19] 0.045 1.14 [1.09–1.20] < 0.0001 1.05 [0.93–1.19] 0.452 Age (years) 15–19 1.00 1.00 1.00 1.00 20–24 1.02 [0.90–1.15] 0.796 1.01 [0.83–1.23] 0.911 1.10 [0.99–1.23] 0.078 1.00 [0.69–1.44] 0.994 25–34 0.92 [0.80–1.05] 0.205 1.07 [0.88–1.29] 0.494 1.16 [1.04–1.30] 0.008 1.10 [0.72–1.67] 0.665 35–49 0.92 [0.79–1.06] 0.232 1.00 [0.81–1.23] 0.974 1.09 [0.97–1.23] 0.154 1.10 [0.69–1.77] 0.679 Marital status Previously/formerly married 1.00 1.00 1.00 1.00 Currently married 0.92 [0.85–0.98] 0.015 0.87 [0.78–0.97] 0.012 0.88 [0.83–0.93] < 0.0001 1.01 [0.82–1.25] 0.915 Highest education completed None 1.00 1.00 1.00 1.00 Primary 0.97 [0.92–1.04] 0.407 0.91 [0.83–0.99] 0.038 1.02 [0.96–1.09] 0.491 0.92 [0.79–1.08] 0.305 Post Primary 0.90 [0.79–1.02] 0.101 0.82 [0.70–0.95] 0.010 0.91 [0.83-1.00] 0.039 0.97 [0.78–1.21] 0.797 Current pregnancy status Not pregnant 1.00 1.00 1.00 1.00 Pregnant wanted then 0.99 [0.90–1.09] 0.836 0.96 [0.83–1.12] 0.596 0.87 [0.79–0.96] 0.006 0.92 [0.73–1.17] 0.515 Pregnant-unintended at the time 1.11 [1.06–1.17] < 0.0001 1.03 [0.87–1.22] 0.731 1.01 [0.92–1.10] 0.851 1.00 [0.76–1.32] 0.999 Total children ever born None 1.00 1.00 1.00 1.00 1–3 1.13 [0.92–1.38] 0.246 1.03 [0.79–1.35] 0.817 0.96 [0.85–1.09] 0.528 1.00 [0.69–1.44] 0.994 4–7 1.30 [1.05–1.61] 0.016 1.08 [0.81–1.42] 0.609 1.01 [0.89–1.14] 0.910 1.10 [0.72-1,67] 0.665 8+ 1.28 [1.03–1.60] 0.023 1.14 [0.85–1.53] 0.394 1.13 [1.00-1.29] 0.057 1.10 [0.69–1.77] 0.679 Residence Urban 1.00 1.00 1.00 1.00 Rural 1.07 [0.94–1.23] 0.321 1.25 [1.02–1.52] 0.029 1.05 [0.95–1.15] 0.344 1.02 [0.86–1.21] 0.792 Working status in the past 12 months Not worked 1.00 1.00 1.00 1.00 Past 12-but not now 0.91 [0.78–1.07] 0.244 1.11 [0.89–1.37] 0.346 1.05 [0.93–1.19] 0.402 1.06 [0.80–1.40] 0.693 Worked currently/on leave 0.93 [0.83–1.04] 0.196 1.01 [0.90–1.12] 0.897 0.90 [0.84–0.96] 0.002 1.00 [0.85–1.18] 0.974 Wealth index Poorest 1.00 1.00 1.00 1.00 Poor 0.98 [0.93–1.03] 0.450 0.96 [0.89–1.03] 0.260 0.88 [0.84–0.92] < 0.0001 0.97 [0.85–1.12] 0.721 Middle 0.96 [0.91–1.02] 0.188 0.89 [0.79-1.00] 0.042 0.80 [0.76–0.85] < 0.0001 0.82 [0.68-1.00] 0.047 Rich 0.87 [0.80–0.95] 0.001 0.73 [0.64–0.84] < 0.0001 0.72 [0.67–0.77] < 0.0001 0.73 [0.59–0.89] 0.002 Richest 0.77 [0.68–0.86] < 0.0001 0.61 [0.50–0.75] < 0.0001 0.50 [0.44–0.57] < 0.0001 0.50 [0.38–0.65] < 0.0001 _cons 0.85 [0.66–1.11] 0.231 0.71 [0.51–0.99] 0.043 0.78 [0.65–0.93] 0.007 0.79 [0.51–1.23] 0.299 N-unweighted observations 1746 1705 7536 786 The effects of IPV were further assessed for a maternal health service; women’s place of delivery of the last birth in the past 5 years, delivery being at home vs public or private health facility, and timely (0–3 months) first ANC visit for last birth in the past 2 years prior to the survey. Overall, the experience of IPV 12 months prior to the surveys was associated with lower delivery at a public or private health facility, but this was statistically significant at the 2016 survey. Women in rural areas, compared to those in urban areas, were less likely to deliver at the public or private health facility, while women with primary or post-primary education were more likely to deliver at the facilities, Fig. 3 . For the ANC visit, timely (0–3) months first ANC visit for the most recent birth in the last 2-years and spousal/intimate partner violence varied across the four surveys, with a pooled adj.PR = 0.88 (0.77, 1.00). Similarly, the association with serious problems accessing healthcare varied with a pooled adj.PR = 0.95(0.76, 1.19), Fig. 3 b. Discussion The study findings indicated that the trends in women experiencing spousal/intimate partner violence (IPV) in the 12 months prior to the survey, as well as women reporting serious problems accessing healthcare when sick (SPAHC), varied across the four UDHS. Overall, there was a significant decline in the number of women reporting at least one specified problem related to SPAHC over the years. Notably, the 2022 survey revealed an increase in two specific problems: the need for permission to visit a healthcare facility and the need for money to pay for treatment. Permission to visit a healthcare facility was the least reported, while the need for money to pay for treatment was the most frequently reported issue. In contrast, there was a significant and consistent decline in the problems related to the distance to healthcare facilities and not wanting to go to the facility alone. Global research shows that women's acceptance of IPV has significantly decreased over the past twenty years. A notable study found that, on average, permissive attitudes toward IPV declined by approximately 6.8% annually from 1999 to 2022 across 83 nations, primarily due to rising standards of living and underreporting of IPV [ 18 – 21 ]. Additionally, financial barriers and socio-cultural barriers like needing permission to go to the health facility have previously been reported as hindrances to access to healthcare, including ANC, particularly in low- and middle-income settings, especially among vulnerable populations [ 22 – 24 ]. However, research indicates that while access to health facilities has improved in some urban areas across different settings, distance to facilities remains a major, persistent barrier to health access in rural and remote regions [ 25 , 26 ]. Research indicates that many women may be hesitant to visit health facilities alone due to a complex combination of safety concerns, socio-cultural expectations, financial constraints, and previous negative experiences with healthcare providers. These factors can vary across different contexts and, therefore, not wanting to go alone continues to serve as a barrier to accessing health services like ANC [ 33 – 36 ]. The results indicate that sexual violence decreased significantly across the four years, and physical and emotional violence saw a reduction until 2016, but both types experienced a rise in 2022. Sexual violence was reported the least, followed by physical violence, while emotional violence was the most frequently reported form of violence. Similar findings have been observed in previous studies across different contexts [ 27 – 30 ]. The study findings also indicate that the effect of IPV on significant healthcare access issues among married women was low, varying between 4% in 2006 and 14% in 2016, with statistical significance noted in 2011. Overall and across the four surveys, women who faced IPV in the 12 months prior to the survey had an increased risk of SPAHC. Of the four individual SPAHC, permission to go for treatment had the highest effects of IPV, and this was followed by not wanting to go alone. These findings emphasize the persistent occurrence of IPV among WRA, especially the socio-cultural barriers and a need to strengthen male involvement in the health and well-being of women, especially when healthcare is needed. This public health issue, along with the afore-mentioned existing barriers that prevent pregnant women from accessing health services like ANC, contributes to negative health outcomes for both mothers and their babies. Despite an overall decline in IPV in recent years, this issue remains an important barrier to women's health and should not be overlooked [ 31 , 32 ]. The study findings further indicate that women in the lower wealth quintile were disproportionately more likely to have serious problems accessing healthcare. However, this disparity was more apparent in women who did not experience IPV. Women experiencing IPV the serious problems accessing healthcare nearly cuts across the wealth quintile gradient, suggesting that IPV is a risky factor in healthcare access irrespective of wealth status. Likewise, previous research also indicates that women in the lowest wealth quintile are indeed disproportionately likely to experience SPAHC. This disparity in access to healthcare is lower among women who do not experience IPV because IPV creates additional, significant barriers to care, regardless of a woman's economic status. Likewise, previous research has shown that women in the lowest wealth quintile are disproportionately likely to experience SPAHC. This disparity is less pronounced among women who do not experience IPV, as IPV creates additional significant barriers to obtaining care, regardless of a woman's economic status. Women who face IPV are much more likely to face challenges in getting a partner's permission to access care, finding money for treatment, and even travelling to a healthcare facility because of insufficient support from their spouses [ 37 – 41 ]. The factors associated with a lower risk of SPAHC across all the surveys included, higher wealth status, being currently married relative to previously married, and post-primary education. Several studies consistently show similar findings, as these factors are widely recognized social determinants of health (SDOH), which contribute to improved utilization of health services and contribute to better health outcomes through various mechanisms [ 42 – 45 ]. Conversely, the study findings show that women with unintended pregnancy and those with 4 or more children ever born reported a higher risk of SPAHC. Previous research also indicates that women with unintended pregnancies and multi-paras were more likely to delay care, less likely to receive the recommended ANC visits, and late initiation of ANC, were at a higher incidence of perinatal depression and IPV, and less likely to receive adequate social support during pregnancy. These all contribute to poorer maternal and child health outcomes. Research further indicates that several interconnected SDOH contribute to the heightened SPAHC for both groups, including socio-economic status, urban-rural residence, family size, and education level [ 46 – 50 ]. The study findings show that the experience of IPV 12 months prior to the surveys was associated with lower delivery at a public or private health facility, especially in 2016. Women in rural areas, compared to those in urban were less likely to deliver at the public or private health facility, while women with primary or post-primary education were more likely to deliver at the facilities. Related studies also show that experiencing IPV was a significant barrier to institutional delivery. This is more common among women in rural areas, often due to physical barriers such as long distances to health facilities, lack of transportation, and limited access to skilled birth attendants compared to urban residents. Also, previous research shows that higher education was a strong predictor of institutional delivery [ 51 – 53 ]. Lastly, the findings show that the timely first ANC visit (0–3 months) for the most recent birth in the last two years was reduced with the occurrence of spousal/intimate partner violence, which varied across the four surveys. Similarly, recent research shows a wide disparity in timely ANC initiation and IPV across settings and other SDOH [ 10 , 54 – 56 ]. Strengths and Limitations of the Study This research contributes to the worldwide discourse on how spousal/ intimate partner violence hinders the advancement of universal maternal health coverage by affecting service use, especially using nationally representative datasets. While self-reported SPAHC, ANC, and IPV may have led to social desirability bias, this influence was countered using skilled and seasoned research assistants. We acknowledge that the elements influencing IPV and its effect on the utilization of ANC services are intricate and diverse, and we did not consider other personal, attitudinal, relational, sociocultural, community, and health-related factors that could be involved. Further research is required to explore these dimensions. Data on ANC-1 and delivery of the last birth in the 5 years preceding the surveys, and the main exposure variable, IPV in the 12 months prior to the survey, do not fully align with respect to exposure-outcome time. In some instances, IPV may have occurred after the last birth. We have, however, minimized the potential bias by limiting the last birth rate that occurred within 2 years prior to the survey. This impacts the sample size that could affect the precision of the estimates. Lastly, only 10% of the DHS2022 data was available for this analysis. This may affect the precision of the estimates due to reduced sample sizes. Also, some estimates may differ from what appears in the final report because the sampled 10% may not be a full representation of the whole survey 2022. Conclusion The study findings indicate the interplay between the various social determinants of health (SDOH), the serious problems with accessing healthcare, accessing maternal health services (first antenatal care-ANC-1 and delivery at the health facilities), and IPV as a key risk factor to these services. There is a need for policymakers and programmers to further strengthen policies and guidelines that can mitigate/prevent the occurrence of IPV among women, as this can result in adverse health outcomes for the women and their pregnancies. Further, tailored interventions should prioritize disadvantaged women, especially those in rural areas, with low education, and in poor/low wealth quintiles. Abbreviations ANC Antenatal Care EA Enumeration Area CAPI Computer-assisted personal interviewing DHS Demographic Health Survey FP Family Planning GLM Generalized Linear Model ICF International Classification of Functioning, Disability and Health IPV Intimate Partner Violence IQR Inter-Quartile Range PR Prevalence Ratio PSU Primary Sampling Unit SD Standard Deviation SDGs Sustainable Development Goals SIPV Spousal/ Intimate Partner Violence SPAHC Serious problems with access to healthcare SRH Sexual Reproductive Health UBOS Uganda Bureau of Statistics UDHS Uganda Demographic and Health Survey UHC Universal Health Coverage UNFPA United Nations Population Fund WHO World Health Organization WRA Women of Reproductive Age Declarations Acknowledgements This work was made possible by funding from the United Nations Population Fund (UNFPA) Uganda in 2025 and implemented by Makerere University School of Public Health. We are very grateful for the funding. Ethics approval and consent to participate The surveys were approved by the Ministry of Health and the Uganda National Council of Science and Technology. The study was conducted in accordance with the Declaration of Helsinki guidelines and regulations, and during each survey, written informed consent was obtained from all study participants who were above 18 years old, and confidentiality was observed. Consent for publication Not applicable Availability of data and materials The dataset generated and analyzed during the study is not publicly available due to confidentiality concerns. However, upon reasonable request, data can be shared by UBOS and stripped of original data identifiers to ensure confidentiality. Only variables used for the analysis will be shared. Competing interests The authors declare that they have no competing interests. Funding This study was made possible through the United Nations Population Fund (UNFPA) Supplies Partnership Programme Author contributions CN : Conceptualization, Statistical analyses, Writing the initial draft, collating feedback, Writing and Review of the final version. SN : Conceptualization, Statistical analyses, Manuscript Review and Collating of feedback, Literature review and writing discussion section, Data analysis, Validation, Review of initial manuscript. TK : Conceptualization, writing the initial draft, review and editing, literature review and writing the discussion section. JMK : Conceptualization, Review of manuscript, and literature for the manuscript, and collating feedback and Validation; FEM : Conceptualization, Statistical analyses, Writing the initial draft, Validation, investigation, Writing draft, Review and editing, Validation. References World Health Organization. Reduction of maternal mortality: a joint WHO/UNFPA/UNICEF World Bank statement. 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Arch Public Health. 2022;80(1):124. 10.1186/s13690-022-00853-y . PMID: 35443697; PMCID: PMC9022289. Tadesse G, Nakie G, Rtbey G, Tinsae T, Fentahun S, Andualem F, Kelebie M, Wassie YA, Tsegaw TK, Kibralew G. The burden and determinants of intimate partner violence against reproductive-age women in four East African countries: evidence from 2021/2023 DHS dataset. Arch Public Health. 2025;83(1):253. 10.1186/s13690-025-01736-8 . PMID: 41108006; PMCID: PMC12534995. Shaikh MA. Prevalence and associated factors of intimate partner violence against women in Ghana: a secondary analysis of the 2022 Demographic and Health Survey. Front Public Health. 2025;13:1685386. 10.3389/fpubh.2025.1685386 . PMID: 41415250; PMCID: PMC12708550. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 11 May, 2026 Reviewers agreed at journal 08 May, 2026 Reviews received at journal 04 Feb, 2026 Reviewers agreed at journal 26 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers invited by journal 21 Jan, 2026 Editor assigned by journal 13 Jan, 2026 Submission checks completed at journal 13 Jan, 2026 First submitted to journal 12 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8584432","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":578811785,"identity":"32b9cc87-5266-4301-bc4c-a360f8fd8945","order_by":0,"name":"Christine Nalwadda","email":"","orcid":"","institution":"Makerere University School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Christine","middleName":"","lastName":"Nalwadda","suffix":""},{"id":578811786,"identity":"10afb85b-750b-4416-a76b-57937b028993","order_by":1,"name":"Sarah Nabukeera","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYHACNgaGAyCaGUwmkKKFLYFkLTwGxGmRn9387DHPGRs58/YzXzfz/LmTx8B++AEzzy/cWgzuHDM35rmRZixzJnfbbd62Z8UMPGkGzLx9eLRIJJhJ83w4nDiDAaSl4XBiA0MOAzNvDx6HzUj/BtTyv34G/5tnt3n+ALXwv8GvheFGDtCWGwcSJCRy2G7zsAG1SABt4fmBx2E3csoN55xJNpwh8czs5ty2Z4ltEs8MDs5twOuwbQ/eHLOTl+BPfnbjzZ87if38yQ8fvPmDx2Fo4AAomhgOMLaRogUCSLBlFIyCUTAKhj0AAFZtV+3IlGUXAAAAAElFTkSuQmCC","orcid":"","institution":"Makerere University School of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Nabukeera","suffix":""},{"id":578811787,"identity":"92866d37-1c47-46f6-8210-a8f6c7aafbb4","order_by":2,"name":"Timothy Kasule","email":"","orcid":"","institution":"United Nations Population 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14:35:01","extension":"xml","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":175112,"visible":true,"origin":"","legend":"","description":"","filename":"3799d9a886bb48cbaf6d0f5f3871da7d1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8584432/v1/6050f56bd7cff936bcc319d7.xml"},{"id":101203307,"identity":"48883c74-e89d-42e3-b2c0-0737ec045bca","added_by":"auto","created_at":"2026-01-27 09:39:21","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":188361,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8584432/v1/3d199eeba56489393b1ec892.html"},{"id":100991232,"identity":"78d85286-b928-4684-b0a4-2d299262412c","added_by":"auto","created_at":"2026-01-23 14:35:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":198198,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIndividual and pooled adjusted prevalence ratio (PR) for the association between serious problems accessing healthcare and spousal/intimate partner violence and currently married\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8584432/v1/c5b9d4a044425205e1506ac2.png"},{"id":101203389,"identity":"6ce73626-4bf5-4736-a95e-338acc3f0e8f","added_by":"auto","created_at":"2026-01-27 09:39:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":251345,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConcentration curves for disparity in serious problems of accessing healthcare by women's wealth stratified by IPV in the past 12 months across the four DHS surveys 2006-2022\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8584432/v1/e5f3adf22dc882cdc25e95cb.png"},{"id":100991234,"identity":"49be6475-04b1-43d5-a3e2-e7f7c8e598cf","added_by":"auto","created_at":"2026-01-23 14:35:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":142009,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdjusted Prevalence ratio (95%CI) for IPV, serious problems accessing healthcare and Residence for women’s place of delivery of the last birth in the past 5 years across the four surveys 2006-2022\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e3b: \u003cstrong\u003eIndividual and pooled adjusted prevalence ratio (PR) for the association between Timely (0-3 months) ANC first visit for the most recent birth in the last two years and serious problems accessing healthcare and spousal/intimate partner violence\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8584432/v1/d59caa1c075a1cd9e882b480.png"},{"id":101207847,"identity":"f6e1966e-91ba-435a-b2db-34826ef300b8","added_by":"auto","created_at":"2026-01-27 10:07:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2246383,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8584432/v1/07ca5965-0f88-47b7-a9b2-a51d4771fdd4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond Healthcare Access: How Intimate Partner Violence Undermines Uganda's Progress Toward Universal Maternal Health Coverage Through Reduced Maternal Health Service Utilization","fulltext":[{"header":"Background","content":"\u003cp\u003eMaternal mortality remains a significant public health issue across the globe. The World Health Organization (WHO) reports that over 303,000 women died worldwide because of complications related to pregnancy and childbirth. To lower maternal mortality, the WHO recommends that every expectant mother have access to maternal health services (MHS) like antenatal care and professional assistance during delivery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. ANC involves support from healthcare providers to ensure the health of both mother and baby during pregnancy, to skilled delivery care provided by trained professionals during delivery and childbirth [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Numerous factors affect access to MHS, including maternal age, education, marital status, and socioeconomic status. Additional key factors are the quality of services as determined by proximity to healthcare facilities, duration of waiting times, views on health workers, as well as community and cultural beliefs [\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Globally, intimate partner violence (IPV) is recognized as a major determinant of poor maternal health outcomes [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIPV is a pattern of behaviour where one partner tries to gain or maintain power and control over another in a relationship, which may be exhibited through physical, sexual, emotional, economic, and psychological abuse or threats. IPV has been reported to affect utilization of MHS [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], which either directly or indirectly exposes women to maternal health challenges, including deaths [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A worldwide meta-analysis revealed that women who faced IPV had 25% reduced chances of receiving sufficient ANC and 20% reduced chances of using skilled delivery services compared to women who did not face IPV [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Relatedly, a distinct systematic review on women's health indicated that experiencing IPV decreased the likelihood of utilizing adequate ANC by half, while physical IPV lowered the odds for receiving four or more visits by approximately 34% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA 2016 national survey in Uganda found that about 60.8% of women experienced IPV in the past 12 months. There was a statistically significant difference between women who experienced any form of IPV and those who did not experience any IPV. Women who faced IPV attended an average of 3.64 ANC visits, compared to 3.82 visits for those without IPV [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Another study indicated a significant link between IPV and fewer ANC visits, even after considering socio-economic factors, and implied that women experiencing IPV are less likely to meet the recommended ANC visit guidelines [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. IPV reportedly reduces MHS utilization through various mechanisms, including psychological and emotional barriers, such as fear, stress and depression, restricted decision making and movement due to lack of financial independence by the woman, as well as fear for further abuse by the partner [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the proportion of women aged 15\u0026ndash;49 in Uganda who received ANC from a skilled provider increased from 97% in 2016 to 99% in 2022, there were inequities in ANC service utilization across the social determinants of health, including region, rural-urban, education level, and wealth quintile [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Additionally, studies have also shown that IPV is prevalent in Uganda, particularly among expectant mothers, and is strongly associated with reduced attendance at ANC and institutional deliveries, increasing the likelihood of negative outcomes for both mothers and infants [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Nine percent of women who had ever been pregnant had experienced physical violence during one or more pregnancies. Fifty-eight percent of ever-married women had experienced a certain form of physical, sexual, or psychological abuse; this was more among the rural women, the less educated, and with regional variations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese disparities hinder the achievement of universal health coverage for all pregnant women in the country, as they disproportionately affect specific groups, ultimately undermining Uganda\u0026rsquo;s goals of achieving comprehensive maternal and child health coverage. While national recommendations support regular screening of pregnant women for IPV, various structural, cultural, and training obstacles hinder effective implementation. Besides, the extent to which IPV influences MHS use and obstructs Uganda's advancement toward universal maternal health coverage is still not well understood. This study examined how IPV undermines Uganda's progress toward universal maternal health coverage through reduced MHS, with a focus on ANC and institutional delivery service utilization. We assessed trends in IPV and its effects on accessing healthcare, and two maternal health services (ANC and Institutional delivery) among women of reproductive age (15\u0026ndash;49 years) in four nationally representative surveys in UgandaThe findings highlight a critical window of opportunity for public health interventions to address IPV among the affected groups to achieve UHC and meet Sustainable Development Goal 3 (SDG3) for Uganda and beyond.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and Study setting\u003c/h2\u003e \u003cp\u003eData for this cross-sectional secondary data analysis were obtained from the four most recent Uganda Demographic and Health Surveys (UDHS) conducted in 2006, 2011, 2016 and 2022, and are publicly available and accessible upon request on the Demographic Health Survey (DHS) Program and the Uganda Bureau of Statistics (UBOS) websites. UBOS, in collaboration Ministry of Health (MoH) and other national stakeholders and international development partners and with the International Classification of Functioning, Disability and Health (ICF), conduct the surveys.\u003c/p\u003e \u003cp\u003eA nationally or sub-nationally representative sample of data from households and women on several indicators, including a module on domestic violence, in addition to key maternal healthcare services and access to healthcare, is collected. In Uganda, the UDHS surveys for 2006 and 2011 had the country stratified into 10 sub-regions, while 2016 and 2022 were further stratified into 15 sub-regions defined by the UBOS. These include Acholi, Ankole, Bukedi, Bugisu, Bunyoro, Busoga, Kampala, Karamoja, Kigezi, Lango, North Buganda, South Buganda, Tooro, Teso, and West Nile [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample size and sampling\u003c/h3\u003e\n\u003cp\u003eThe DHS is a complex survey design that utilizes a multistage stratified sampling to select households. The country is divided into regions, and the population within each region is stratified into urban and rural areas. Clusters or enumeration areas (EAs) within each stratified area are randomly selected, and these form the primary sampling units (PSUs). The PSU selection is based on a probability proportional to size, which considers the number of households. Through the two-stage cluster sampling approach, selection of the clusters/EAs was the first stage, while in the second stage, households in each PSU were randomly selected following the listing of all households within the PSU. A fixed number of households within each PSU is randomly selected using systematic sampling. A total of 15 regions were considered in the 2016 and 2022 UDHS, while the 2006 and 2011 surveys had 10 regions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo simplify the household listing process, larger EAs (those with more than 300 households) are segmented. From these segments, only one is selected for the survey, using a probability proportional to the size of the segment, and the household listing is conducted solely in the chosen segment. Therefore, a UDHS cluster can either be an EA or a segment of an EA [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In total, a representative sample of 9,864 households was selected for the 2006 UDHS, 10,086 households for 2011, 20,880 households for 2016, and 22,907 for 2022. For this analysis, we considered ever-married women (currently/in union/living with a partner as if married, or formerly married) as per the domestic violence model that focused on IPV in the past 12 months prior to the survey\u003c/p\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eAll women aged 15\u0026ndash;49 years who were either permanent residents of the selected households or visitors who stayed in the household the night before the survey were eligible to be interviewed [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This analysis only considered ever-married women (currently/in union/living with a partner as if married or formerly married) as per the domestic violence module.\u003c/p\u003e \u003cp\u003eNote also that ever-married women are women who self-report as being married, divorced, separated, or widowed, or living with or having ever lived with a man as if married. Thus, a \u0026ldquo;partner\u0026rdquo; is a man with whom the respondent lives or lived as if married. A previous husband/partner is a husband/partner other than the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eFour questionnaires are used to collect data in the UDHS, and among these are the Household Questionnaire and the Women\u0026rsquo;s Questionnaire. The questionnaires, based on The DHS Program\u0026rsquo;s model questionnaires, are adapted to reflect the population and health issues relevant to Uganda. In addition, information on the survey fieldworkers was collected through a self-administered Fieldworker Questionnaire. After the preparation of the questionnaires in English, the questionnaires were then translated into eight major languages: Ateso, Ngakarimojong, Luganda, Lugbara, Luo, Runyankole-Rukiga, Runyoro-Rutooro, and Lusoga. The Household Women\u0026rsquo;s quetionnaire is programmed into tablet computers to facilitate computer-assisted personal interviewing (CAPI) for data collection purposes, with the capability to choose any of the eight languages for each questionnaire [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eData on domestic violence in DHS surveys comes from an optional module of questions, and indicators are available for some, but not all, countries, and for only one randomly selected woman per household among all eligible women in the household. This DHS Program approach is in accordance with the WHO guidelines \u0026ldquo;Putting Women First: Ethical and Safety Recommendations for Research on Domestic Violence against Women\u0026rdquo;, World Health Organization, 2001. Therefore, the number of women for the domestic violence module will always be less than the number of women selected for the complete DHS individual interview. Questions largely ask about violence perpetrated by the current husband/partner for women who are currently married and the most recent husband/partner for women who are currently divorced, separated or widowed.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eThe analysis was focused on ever-married women (currently/in union/living with a partner as if married or formerly married) because IPV were only captured in relation to a current or most recent husband/partner for women who are divorced/separated. The primary outcome for this analysis was serious problems accessing healthcare when sick, and the secondary outcome was maternal health services, defined as the place of delivery of the most recent birth in the 5 years preceding the survey.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e1). Serious problems accessing health care for themselves when they are sick, and these included four key items, i) getting permission to go for treatment, ii) getting money for treatment, iii) distance to the health facility and iv) not wanting to go alone. A composite measure, serious problems with access to healthcare (SPAHC), was constructed as the primary outcome when women reported at least one problem accessing health care and compared to not reporting any of these four items.\u003c/p\u003e\u003cp\u003e2). For the secondary outcomes, we constructed i) a place of delivery variable and grouped responses into public or private health facility, compared to at home or another place not a health facility for the last birth within the last 5-years of the survey; ii) timely attendance of the first antenatal care visit of the last birth that occurred within the last 2 years before the survey; a women was assigned timely ANC-1 when she attended in the first trimester (0\u0026ndash;3 months) of the last birth within 2 years.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe key exposure variable was IPV in the 12 months preceding the survey based on the three experiences of violence,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ea) Experienced spousal/intimate partner \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003esexual violence\u003c/span\u003e in the 12 months preceding the survey by their current or most recent husbands/partners used the following items/questions i) ever been physically forced into unwanted sex by husband/partner, ii) ever been forced into other unwanted sexual acts by husband/partner, iii) ever been physically forced to perform sexual acts respondent didn't want to.\u003c/p\u003e\u003cp\u003eb)Experienced spousal/intimate partner \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ephysical violence\u003c/span\u003e in the 12 months preceding the survey by their current or most recent husbands/partners had the following items/questions i) ever been pushed, shook or had something thrown by husband/partner, ii) ever been slapped by husband/partner, iii) ever been punched with fist or hit by something harmful by husband/partner, iv) ever been kicked or dragged by husband/partner, v) ever been strangled or burnt by husband/partner, vi) ever been threatened with knife/gun or other weapon by husband/partner, vii) ever clinically significant (CS) physical violence by husband/partner, viii) Ever had an arm twisted or hair pulled by husband/partner?\u003c/p\u003e\u003cp\u003ec) Experienced spousal/intimate partner \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eemotional violence\u003c/span\u003e in the 12 months preceding the survey by their current or most recent husbands/partners, had the following items/questions: i) ever been humiliated by husband/partner, ii) ever been threatened with harm by husband/partner, iii) ever been insulted or made to feel bad by husband/partner.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor all three experiences, physical, sexual and emotional, women who responded often or sometimes to any of the items/questions were coded as \u0026ldquo;Yes\u0026rdquo; to reflect experience in the 12 months, while those with responses of never or yes but not within 12 months were coded as \u0026ldquo;No\u0026rdquo;. A composite spousal/intimate partner violence (IPV) was constructed and defined as yes-experience any of the 3-violences coded as \u0026ldquo;1\u0026rdquo; or \u0026ldquo;0\u0026rdquo;, if none of the three-violences were coded as yes.\u003c/p\u003e \u003cp\u003ePotential confounder variables considered for this analysis included, women age in completed years at time of survey categorized as \u003cem\u003e15\u0026ndash;19, 20\u0026ndash;24, 25\u0026ndash;34, and 35\u0026ndash;49 years\u003c/em\u003e; ever-married status (\u003cem\u003ecurrently married/Living together as if married/Divorced or separated\u003c/em\u003e); Residence categorized as \u003cem\u003eUrban and Rural\u003c/em\u003e; Education, the highest level of education attained by the woman categorized as \u003cem\u003eNone, Primary, Post primary (Secondary and Tertiar\u003c/em\u003ey\u003cem\u003e)\u003c/em\u003e; current pregnancy status \u003cem\u003e(not pregnant, pregnant-wanted, pregnant unwanted at time)\u003c/em\u003e, total number of children ever-born \u003cem\u003e(none, 1\u0026ndash;3, 4\u0026ndash;7, 8+)\u003c/em\u003e, working status past 12 months \u003cem\u003e(not worked, worked past 12 months but not at time of survey, working currently/on leave\u003c/em\u003e) and wealth index (\u003cem\u003epoorest, poor, middle, rich richest\u003c/em\u003e),\u003c/p\u003e \u003cp\u003eThe wealth-index is based on measures by ownership/possession of household assets (Communication: cell or landline phone, computer, radio, TV; Transport: bicycle, motorcycle, car; Source of power: electricity, generator, solar, and materials for building/construction, ownership of the home, indoor bathroom and access to running water [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Management\u003c/h2\u003e \u003cp\u003eWe merged all four datasets prior to the analysis, each with appropriate variables common across the four surveys into one dataset, after examining that all the key variables, outcome and explanatory, for this analysis were defined and labelled the same. The complex survey design variables were also maintained, including strata, clusters, and the weight variable, to enable accounting for the complex design during the analyses. For this analysis, the domestic violence weight variable, d005, was used as the guideline (Croft, Trevor N., Aileen M. J. Marshall, Courtney K. Allen, et al. 2018. Guide to DHS Statistics. Rockville, Maryland, USA: ICF).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData was analyzed using Stata version 18. Exploratory data analysis was conducted to generate descriptive statistics for all the key variables. Percentages for categorical variables and mean or medians with corresponding standard deviations (SD) or inter-quartile range (IQR) were obtained for the socio-economic, demographic and health variables, as well as for the primary, secondary outcome, and key exposure variable spousal/intimate partner violence variables. Frequencies for the variables were presented as unweighted, while means and proportions were weighted. We determined the trends in primary, secondary outcomes and the IPV over the four surveys. The percentage distribution of these variables was analyzed for linear chi-square for trends across the four UDHS survey periods using the trend command.\u003c/p\u003e \u003cp\u003eWe determined the association between IPV and the primary (serious problem accessing healthcare when sick) and secondary (place of delivery of last birth) outcomes. The outcomes were binary, and we therefore used a \u0026ldquo;modified\u0026rdquo; Poisson regression model via a generalized linear model (GLM) with Poisson family and log link was conducted to provide the prevalence ratios (PRs) as a measure of association. Prevalence ratios had corresponding 95% confidence intervals. The effects of the IPV on serious problems accessing healthcare across the four DHS were pooled to provide a single measure of effect for the 12 months prior to each survey. The pooled effects were analyzed through meta-analysis using the two-stage approach, where regression coefficients and standard errors (SE) were pooled. In a sub-analysis, we also considered each of the serious problem items, permission to go for treatment, needed money for treatment, distance to health facility, and not wanting to go alone, as outcomes.\u003c/p\u003e \u003cp\u003eWe also conducted an equity analysis to determine disparity in serious problems accessing healthcare by women's health status, comparing those experiencing SIPV to those who did not report. We used concentration curves and Errygen concentration indices. All analyses were weighted and accounted for a multi-stage cluster design achieved via the survey set (svyset) command in STATA software version 18.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003eThree protective measures were integrated into the UDHS questionnaires, adhering to the ethical and safety standards established by the World Health Organization for research on domestic violence (WHO, 2001). Questions concerning violence were directed to only one eligible individual within each household. Among a selection of three households, one was specifically selected for a violence interview with a female respondent [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom the last two homes, one was pre-selected for a violence interview featuring a male participant. In cases where there are multiple women in a household, the participant for this section was randomly picked utilizing a specifically designed, straightforward selection technique (based on the \u0026lsquo;Kish Grid\u0026rsquo;) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], which was included in the Household Questionnaire. Interviewing just one individual per household with the violence module ensures that the chosen respondent feels assured that others in the household will not discuss the types of questions posed to the selected individual. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003efrom the respondent for the survey was obtained at the beginning of the individual interview. Additionally, prior to the violence section, respondents were presented with a statement that highlighted the sensitivity of the upcoming questions and assured them that their responses would remain confidential. The violence module was conducted only if privacy could be guaranteed. If privacy could not be ensured, the interviewer was instructed to skip this module, thank the respondent, and conclude the interview. In cases where a translator was needed, respondents were not asked questions from the violence module to protect their privacy. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTrends in the women experiencing intimate partner violence (IPV) in the 12 months prior to the survey, and women reporting serious problems accessing healthcare (SPAHC), varied over the four UDHS. Overall, SPAHC in at least one specified problem dropped from 83.1% in 2006 to 60% in 2022, p-for-trend\u0026thinsp;\u0026lt;\u0026thinsp;0.0001. Individually all the four specified problems declined but with an increase in the last survey in 2022 for i) getting permission to go (8.8% in 2006 to 5.12% in 2016, and to 7.4% in 2022), ii) need money for treatment (68% in 2006 to 46.4% in 2016, and to 53% in 2022), while the last two steadily declined iii) distance to health facility ( 60% in 2006 to 36.7% in 2022, p-for-trend\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and iv) not wanting to go alone (24.6% in 2006 to 12.4% in 2022 p-for-trend\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Getting permission to go to the least reported serious problem towards accessing healthcare, while the money needed for treatment was the most reported serious problem.\u003c/p\u003e \u003cp\u003eAlso, SIPV declined across the four DHS with women reporting at least one of the three specific violence acts dropping from 52.6% in 2006 to 39.2% in 2016, then back up to 45% in 2022. Sexual violence steadily declined from 23.5% in 2006 to 11.8% in 2022, p-for-trend\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, while physical and emotional violence declined up to 2016, but both experienced an increase in 2022. Sexual violence was the least reported, followed by physical, while emotional was the most mentioned act of violence, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eSerious problems accessing healthcare and Intimate Partner Violence (IPV) among ever-married women across the four UDHS\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eDHS year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2006\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2011\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-for-trends\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEver-married women (15-49years): weighted\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,598\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,588\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6,879\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e824\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSerious problems with accessing healthcare\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny of the 4 problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSpecific serious problem mentioned\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ei) Permission to go for treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eii) Need money for treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eiii) Distance to health facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eiv) Not wanting to go alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntimate partner violence in the past 12 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny of the 3 forms of violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSpecific violence mentioned\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ei) Physical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eii) Sexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eiii) Emotional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe effect of SIPV on serious problems in accessing healthcare among the ever-married women was minimal, ranging from 4% in 2006 to 14% in 2016, and was statistically significant in 2011, adj.PR\u0026thinsp;=\u0026thinsp;1.09(1.002, 1.191) and in 2016, adj.PR\u0026thinsp;=\u0026thinsp;1.14(1.093, 1.198). Pooled analysis of coefficients of SIPV resulted in 8% higher risk of serious problems accessing healthcare for women who experienced SIPV in the 12 months prior to the survey, pooled adj.PR\u0026thinsp;=\u0026thinsp;1.08(1.02, 1.15), Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. In the analysis for each of the four individual serious problems of accessing healthcare as an outcome, permission to go for treatment had the highest effects of IPV with adj.PR\u0026thinsp;=\u0026thinsp;1.52(0.805, 2.872) in 2022 to adj.PR\u0026thinsp;=\u0026thinsp;2.61 (1.478, 4.614) in 2011, and this was followed by not wanting to go alone, adj.PR\u0026thinsp;=\u0026thinsp;1.16(0.915, 1.465) in 2011 to adj.PR\u0026thinsp;=\u0026thinsp;1.66(1.096, 2.517) in 2022, Table\u0026nbsp;2.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTable 2: Effects of IPV in the past 12 months on the problem of accessing healthcare among ever-married women\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"761\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 493px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProblem accessing healthcare\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperienced any of the 3 IPV-12-month vs none\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAny of the 4 problems\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePermission to go for treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMoney needed for treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistance to health facility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot wanting to go alone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eDHS year (number of observations)\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cu\u003e*Adj.PR(95%CI)\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cu\u003e*Adj.PR(95%CI)\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cu\u003e*Adj.PR(95%CI)\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cu\u003e*Adj.PR(95%CI)\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cu\u003e*Adj.PR(95%CI)\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eDHS2006 (1746)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.04 (0.994, 1.096)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.81 (1.240,2.641)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e1.07 (1.003,1.146)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.03 (0.937,1.142)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.19 (0.961,1.464)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eDHS2011 (1705)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.09 (1.002, 1.191)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;2.61 (1.478,4.614)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e1.13 (0.994,1.288)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.03 (0.908,1.177)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.16 (0.915,1.465)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eDHS2016 (7536)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;1.14 (1.093,1.198)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.78 (1.349,2.349)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e1.18 (1.111, 1.254)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.05 (0.977,1.124)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.31 (1.181,1.458)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eDHS2022 (786)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.05 (0.925,1.190)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.52 (0.805,2.872)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e1.06 (0.915,1.234)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.13 (0.937,1.361)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;1.66 (1.096,2.517)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 761px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNote: * adjusted for: Age, marital status (current or formerly married), education, wealth quintile. Working status past 12 months, residence, total children ever born, current pregnancy status,\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003c/br\u003e\u003cp\u003eTo further understand the effect of IPV on serious problems in accessing healthcare, we assess for disparity in serious problems accessing healthcare by increasing women's wealth status, stratified by experience of IPV in the 12 months prior to the survey. Overall, women in the lower wealth quintile were disproportionately more likely to have serious problems accessing healthcare. However, this disparity was lower in women who did not experience IPV, apart from the 2006 survey, where the disparity was largely similar (Coindex \u0026minus;\u0026thinsp;0.1956 compared to -0.2068), Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFactors associated with a lower risk of serious problems accessing healthcare across all the surveys included were higher wealth status, with nearly a 20% or more reduced risk for women in the middle-to richest quintile relative to the poorest. Similarly, a reduction in the risk of problems accessing healthcare was observed in women reporting being currently married compared to the formerly married women, ranging from 8% in 2006 to 13% in 2016, but not in 2022, adj.PR\u0026thinsp;=\u0026thinsp;1.01(0.82, 1.25). In the pooled analysis, being currently married was associated with a lower risk of serious problems accessing healthcare, pooled adj.PR\u0026thinsp;=\u0026thinsp;0.91(0.86, 0.98). Post-primary relative to no education also had a lower risk, but these were not statistically significant. Women with unintended pregnancy compared to non-pregnant and those with 4 or children ever-born (CEB) reported a higher risk of serious problems accessing healthcare, but the association was statistically significant mainly in the 2006 survey, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eIPV (Physical, Sexual and Emotional) experience in the past 12 months by partner among ever-married women and serious problem access to healthcare\u003c/span\u003e\u003c/p\u003e \u003cdiv class=\"Credit\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e(permission to go/money needed for treatment/distance to facility/not wanting to go alone\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome: Problems with accessing healthcare\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMain Exposure-IPV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdj.PR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdj.PR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdj.PR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdj.PR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExperienced any of the 3 IPV past 12 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.04 [0.99\u0026ndash;1.10]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.09 [1.00-1.19]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.14 [1.09\u0026ndash;1.20]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.05 [0.93\u0026ndash;1.19]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.02 [0.90\u0026ndash;1.15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.796\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.01 [0.83\u0026ndash;1.23]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.911\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.10 [0.99\u0026ndash;1.23]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00 [0.69\u0026ndash;1.44]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.994\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.92 [0.80\u0026ndash;1.05]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.07 [0.88\u0026ndash;1.29]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.494\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.16 [1.04\u0026ndash;1.30]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.10 [0.72\u0026ndash;1.67]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.665\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.92 [0.79\u0026ndash;1.06]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00 [0.81\u0026ndash;1.23]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.974\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.09 [0.97\u0026ndash;1.23]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.10 [0.69\u0026ndash;1.77]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreviously/formerly married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrently married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.92 [0.85\u0026ndash;0.98]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.87 [0.78\u0026ndash;0.97]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.88 [0.83\u0026ndash;0.93]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.01 [0.82\u0026ndash;1.25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.915\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHighest education completed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.97 [0.92\u0026ndash;1.04]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.91 [0.83\u0026ndash;0.99]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.02 [0.96\u0026ndash;1.09]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.92 [0.79\u0026ndash;1.08]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost Primary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.90 [0.79\u0026ndash;1.02]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.82 [0.70\u0026ndash;0.95]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.91 [0.83-1.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.97 [0.78\u0026ndash;1.21]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.797\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent pregnancy status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot pregnant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePregnant wanted then\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.99 [0.90\u0026ndash;1.09]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.96 [0.83\u0026ndash;1.12]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.596\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.87 [0.79\u0026ndash;0.96]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.92 [0.73\u0026ndash;1.17]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.515\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePregnant-unintended at the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.11 [1.06\u0026ndash;1.17]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.03 [0.87\u0026ndash;1.22]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.731\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.01 [0.92\u0026ndash;1.10]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.851\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00 [0.76\u0026ndash;1.32]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal children ever born\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.13 [0.92\u0026ndash;1.38]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.03 [0.79\u0026ndash;1.35]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.817\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.96 [0.85\u0026ndash;1.09]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.528\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00 [0.69\u0026ndash;1.44]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.994\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.30 [1.05\u0026ndash;1.61]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.08 [0.81\u0026ndash;1.42]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.609\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.01 [0.89\u0026ndash;1.14]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.910\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.10 [0.72-1,67]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.665\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.28 [1.03\u0026ndash;1.60]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.14 [0.85\u0026ndash;1.53]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.13 [1.00-1.29]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.10 [0.69\u0026ndash;1.77]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.07 [0.94\u0026ndash;1.23]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.25 [1.02\u0026ndash;1.52]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.05 [0.95\u0026ndash;1.15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.344\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.02 [0.86\u0026ndash;1.21]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.792\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWorking status in the past 12 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot worked\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePast 12-but not now\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.91 [0.78\u0026ndash;1.07]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.11 [0.89\u0026ndash;1.37]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.05 [0.93\u0026ndash;1.19]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.402\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.06 [0.80\u0026ndash;1.40]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.693\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorked currently/on leave\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.93 [0.83\u0026ndash;1.04]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.01 [0.90\u0026ndash;1.12]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.897\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.90 [0.84\u0026ndash;0.96]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00 [0.85\u0026ndash;1.18]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.974\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWealth index\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoorest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98 [0.93\u0026ndash;1.03]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.96 [0.89\u0026ndash;1.03]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.88 [0.84\u0026ndash;0.92]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.97 [0.85\u0026ndash;1.12]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.721\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.96 [0.91\u0026ndash;1.02]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.89 [0.79-1.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.80 [0.76\u0026ndash;0.85]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.82 [0.68-1.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRich\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.87 [0.80\u0026ndash;0.95]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.73 [0.64\u0026ndash;0.84]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.72 [0.67\u0026ndash;0.77]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.73 [0.59\u0026ndash;0.89]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRichest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.77 [0.68\u0026ndash;0.86]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.61 [0.50\u0026ndash;0.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.50 [0.44\u0026ndash;0.57]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.50 [0.38\u0026ndash;0.65]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e_cons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.85 [0.66\u0026ndash;1.11]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.71 [0.51\u0026ndash;0.99]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.78 [0.65\u0026ndash;0.93]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.79 [0.51\u0026ndash;1.23]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.299\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eN-unweighted observations\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1746\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1705\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e7536\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e786\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe effects of IPV were further assessed for a maternal health service; women\u0026rsquo;s place of delivery of the last birth in the past 5 years, delivery being at home vs public or private health facility, and timely (0\u0026ndash;3 months) first ANC visit for last birth in the past 2 years prior to the survey. Overall, the experience of IPV 12 months prior to the surveys was associated with lower delivery at a public or private health facility, but this was statistically significant at the 2016 survey. Women in rural areas, compared to those in urban areas, were less likely to deliver at the public or private health facility, while women with primary or post-primary education were more likely to deliver at the facilities, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e. For the ANC visit, timely (0\u0026ndash;3) months first ANC visit for the most recent birth in the last 2-years and spousal/intimate partner violence varied across the four surveys, with a pooled adj.PR\u0026thinsp;=\u0026thinsp;0.88 (0.77, 1.00). Similarly, the association with serious problems accessing healthcare varied with a pooled adj.PR\u0026thinsp;=\u0026thinsp;0.95(0.76, 1.19), Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003eb.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study findings indicated that the trends in women experiencing spousal/intimate partner violence (IPV) in the 12 months prior to the survey, as well as women reporting serious problems accessing healthcare when sick (SPAHC), varied across the four UDHS. Overall, there was a significant decline in the number of women reporting at least one specified problem related to SPAHC over the years. Notably, the 2022 survey revealed an increase in two specific problems: the need for permission to visit a healthcare facility and the need for money to pay for treatment. Permission to visit a healthcare facility was the least reported, while the need for money to pay for treatment was the most frequently reported issue. In contrast, there was a significant and consistent decline in the problems related to the distance to healthcare facilities and not wanting to go to the facility alone.\u003c/p\u003e \u003cp\u003eGlobal research shows that women's acceptance of IPV has significantly decreased over the past twenty years. A notable study found that, on average, permissive attitudes toward IPV declined by approximately 6.8% annually from 1999 to 2022 across 83 nations, primarily due to rising standards of living and underreporting of IPV [\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Additionally, financial barriers and socio-cultural barriers like needing permission to go to the health facility have previously been reported as hindrances to access to healthcare, including ANC, particularly in low- and middle-income settings, especially among vulnerable populations [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, research indicates that while access to health facilities has improved in some urban areas across different settings, distance to facilities remains a major, persistent barrier to health access in rural and remote regions [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Research indicates that many women may be hesitant to visit health facilities alone due to a complex combination of safety concerns, socio-cultural expectations, financial constraints, and previous negative experiences with healthcare providers. These factors can vary across different contexts and, therefore, not wanting to go alone continues to serve as a barrier to accessing health services like ANC [\u003cspan additionalcitationids=\"CR34 CR35\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results indicate that sexual violence decreased significantly across the four years, and physical and emotional violence saw a reduction until 2016, but both types experienced a rise in 2022. Sexual violence was reported the least, followed by physical violence, while emotional violence was the most frequently reported form of violence. Similar findings have been observed in previous studies across different contexts [\u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study findings also indicate that the effect of IPV on significant healthcare access issues among married women was low, varying between 4% in 2006 and 14% in 2016, with statistical significance noted in 2011. Overall and across the four surveys, women who faced IPV in the 12 months prior to the survey had an increased risk of SPAHC. Of the four individual SPAHC, permission to go for treatment had the highest effects of IPV, and this was followed by not wanting to go alone. These findings emphasize the persistent occurrence of IPV among WRA, especially the socio-cultural barriers and a need to strengthen male involvement in the health and well-being of women, especially when healthcare is needed. This public health issue, along with the afore-mentioned existing barriers that prevent pregnant women from accessing health services like ANC, contributes to negative health outcomes for both mothers and their babies. Despite an overall decline in IPV in recent years, this issue remains an important barrier to women's health and should not be overlooked [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study findings further indicate that women in the lower wealth quintile were disproportionately more likely to have serious problems accessing healthcare. However, this disparity was more apparent in women who did not experience IPV. Women experiencing IPV the serious problems accessing healthcare nearly cuts across the wealth quintile gradient, suggesting that IPV is a risky factor in healthcare access irrespective of wealth status.\u003c/p\u003e \u003cp\u003eLikewise, previous research also indicates that women in the lowest wealth quintile are indeed disproportionately likely to experience SPAHC. This disparity in access to healthcare is lower among women who do not experience IPV because IPV creates additional, significant barriers to care, regardless of a woman's economic status. Likewise, previous research has shown that women in the lowest wealth quintile are disproportionately likely to experience SPAHC. This disparity is less pronounced among women who do not experience IPV, as IPV creates additional significant barriers to obtaining care, regardless of a woman's economic status. Women who face IPV are much more likely to face challenges in getting a partner's permission to access care, finding money for treatment, and even travelling to a healthcare facility because of insufficient support from their spouses [\u003cspan additionalcitationids=\"CR38 CR39 CR40\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe factors associated with a lower risk of SPAHC across all the surveys included, higher wealth status, being currently married relative to previously married, and post-primary education. Several studies consistently show similar findings, as these factors are widely recognized social determinants of health (SDOH), which contribute to improved utilization of health services and contribute to better health outcomes through various mechanisms [\u003cspan additionalcitationids=\"CR43 CR44\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Conversely, the study findings show that women with unintended pregnancy and those with 4 or more children ever born reported a higher risk of SPAHC. Previous research also indicates that women with unintended pregnancies and multi-paras were more likely to delay care, less likely to receive the recommended ANC visits, and late initiation of ANC, were at a higher incidence of perinatal depression and IPV, and less likely to receive adequate social support during pregnancy. These all contribute to poorer maternal and child health outcomes. Research further indicates that several interconnected SDOH contribute to the heightened SPAHC for both groups, including socio-economic status, urban-rural residence, family size, and education level [\u003cspan additionalcitationids=\"CR47 CR48 CR49\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study findings show that the experience of IPV 12 months prior to the surveys was associated with lower delivery at a public or private health facility, especially in 2016. Women in rural areas, compared to those in urban were less likely to deliver at the public or private health facility, while women with primary or post-primary education were more likely to deliver at the facilities. Related studies also show that experiencing IPV was a significant barrier to institutional delivery. This is more common among women in rural areas, often due to physical barriers such as long distances to health facilities, lack of transportation, and limited access to skilled birth attendants compared to urban residents. Also, previous research shows that higher education was a strong predictor of institutional delivery [\u003cspan additionalcitationids=\"CR52\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Lastly, the findings show that the timely first ANC visit (0\u0026ndash;3 months) for the most recent birth in the last two years was reduced with the occurrence of spousal/intimate partner violence, which varied across the four surveys. Similarly, recent research shows a wide disparity in timely ANC initiation and IPV across settings and other SDOH [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR55\" citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations of the Study\u003c/h2\u003e \u003cp\u003eThis research contributes to the worldwide discourse on how spousal/ intimate partner violence hinders the advancement of universal maternal health coverage by affecting service use, especially using nationally representative datasets. While self-reported SPAHC, ANC, and IPV may have led to social desirability bias, this influence was countered using skilled and seasoned research assistants.\u003c/p\u003e \u003cp\u003eWe acknowledge that the elements influencing IPV and its effect on the utilization of ANC services are intricate and diverse, and we did not consider other personal, attitudinal, relational, sociocultural, community, and health-related factors that could be involved. Further research is required to explore these dimensions.\u003c/p\u003e \u003cp\u003eData on ANC-1 and delivery of the last birth in the 5 years preceding the surveys, and the main exposure variable, IPV in the 12 months prior to the survey, do not fully align with respect to exposure-outcome time. In some instances, IPV may have occurred after the last birth. We have, however, minimized the potential bias by limiting the last birth rate that occurred within 2 years prior to the survey. This impacts the sample size that could affect the precision of the estimates.\u003c/p\u003e \u003cp\u003eLastly, only 10% of the DHS2022 data was available for this analysis. This may affect the precision of the estimates due to reduced sample sizes. Also, some estimates may differ from what appears in the final report because the sampled 10% may not be a full representation of the whole survey 2022.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e The study findings indicate the interplay between the various social determinants of health (SDOH), the serious problems with accessing healthcare, accessing maternal health services (first antenatal care-ANC-1 and delivery at the health facilities), and IPV as a key risk factor to these services. There is a need for policymakers and programmers to further strengthen policies and guidelines that can mitigate/prevent the occurrence of IPV among women, as this can result in adverse health outcomes for the women and their pregnancies. Further, tailored interventions should prioritize disadvantaged women, especially those in rural areas, with low education, and in poor/low wealth quintiles.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntenatal Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnumeration Area\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAPI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputer-assisted personal interviewing\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDemographic Health Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFamily Planning\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGLM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneralized Linear Model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Classification of Functioning, Disability and Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntimate Partner Violence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInter-Quartile Range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrevalence Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary Sampling Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDGs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSustainable Development Goals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSIPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpousal/ Intimate Partner Violence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPAHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSerious problems with access to healthcare\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSRH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexual Reproductive Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUBOS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUganda Bureau of Statistics\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUDHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUganda Demographic and Health Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversal Health Coverage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUNFPA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Nations Population Fund\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWRA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWomen of Reproductive Age\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was made possible by funding from the United Nations Population Fund (UNFPA) Uganda in 2025 and implemented by Makerere University School of Public Health. \u0026nbsp;We are very grateful for the funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe surveys were approved by the Ministry of Health and the Uganda National Council of Science and Technology. The study was conducted in accordance with the Declaration of Helsinki guidelines and regulations, and during each survey, written informed consent was obtained from all study participants who were above 18 years old, and confidentiality was observed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset generated and analyzed during the study is not publicly available due to confidentiality concerns. However, upon reasonable request, data can be shared by UBOS and stripped of original data identifiers to ensure confidentiality. Only variables used for the analysis will be shared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was made possible through the United Nations Population Fund (UNFPA) Supplies Partnership Programme\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCN\u003c/strong\u003e: Conceptualization, Statistical analyses, Writing the initial draft, collating feedback, Writing and Review of the final version. \u003cstrong\u003eSN\u003c/strong\u003e: Conceptualization, Statistical analyses, Manuscript Review and Collating of feedback, Literature review and writing discussion section, Data analysis, Validation, Review of initial manuscript. \u003cstrong\u003eTK\u003c/strong\u003e: Conceptualization, writing the initial draft, review and editing, literature review and writing the discussion section. \u0026nbsp; \u003cstrong\u003eJMK\u003c/strong\u003e: Conceptualization, Review of manuscript, and literature for the manuscript, and collating feedback and Validation; \u003cstrong\u003eFEM\u003c/strong\u003e: Conceptualization, Statistical analyses, Writing the initial draft, Validation, investigation, Writing draft, Review and editing, Validation. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. 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The burden and determinants of intimate partner violence against reproductive-age women in four East African countries: evidence from 2021/2023 DHS dataset. Arch Public Health. 2025;83(1):253. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13690-025-01736-8\u003c/span\u003e\u003cspan address=\"10.1186/s13690-025-01736-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 41108006; PMCID: PMC12534995.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaikh MA. Prevalence and associated factors of intimate partner violence against women in Ghana: a secondary analysis of the 2022 Demographic and Health Survey. Front Public Health. 2025;13:1685386. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpubh.2025.1685386\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2025.1685386\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 41415250; PMCID: PMC12708550.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"contraception-and-reproductive-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"carm","sideBox":"Learn more about [Contraception and Reproductive Medicine](http://contraceptionmedicine.biomedcentral.com)","snPcode":"40834","submissionUrl":"https://submission.nature.com/new-submission/40834/3","title":"Contraception and Reproductive Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intimate Partner Violence, Antenatal Care, Maternal Health Services","lastPublishedDoi":"10.21203/rs.3.rs-8584432/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8584432/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEvidence suggests that Intimate Partner Violence (IPV) is associated with reduced use of maternal health services (MHS), including ANC, institutional deliveries, and use of modern contraception. The effects of IPV on MHS work through mechanisms such as psychological barriers, alongside restricted decision-making and movement related to financial dependence, and fear of further abuse. We assessed trends in IPV and its effects on accessing healthcare, and two maternal health services (ANC and institutional delivery) among women of reproductive age (15\u0026ndash;49 years) in four nationally representative surveys in Uganda.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this study, we conducted a cross-sectional analysis of secondary data, utilizing information from four Uganda Demographic and Health Surveys (UDHS) that were carried out in 2006, 2011, 2016, and 2022. The UDHS uses a multistage stratified sampling methodology to select households from both urban and rural areas across regions in Uganda. Women between the ages of 15 and 49 years who were either residents or visitors in these households were eligible for interviews. Data for this analysis are drawn from the domestic violence module that generates information on spousal/intimate partners violence among ever-married women. Both exploratory and inferential data analyses were conducted to generate descriptive statistics for key variables, and a modified Poisson regression model to provide evidence for the association between maternal health services and IPV using prevalence ratios (PRs) with 95% confidence intervals as measures of association. Analyses were weighted and accounted for a multi-stage cluster design, conducted using svyset command in STATA version 18.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTrends in the women experiencing intimate partner violence (IPV) in the 12 months prior to the survey, and women reporting serious problems accessing healthcare (SPAHC) varied over the four UDHS. Overall, SPAHC dropped from 83.1% in 2006 to 60% in 2022, p-for-trend\u0026thinsp;\u0026lt;\u0026thinsp;0.000. Similarly, IPV declined in the same period, dropping from 52.6% in 2006 to 39.2% in 2016, but increased to 45% in 2022. The overall pooled effect of IPV on SPAHC across the four DHS was about 8% higher among the ever-married women reporting IPV. The effects of IPV the two maternal health service; women\u0026rsquo;s place of delivery of the last birth in the past 5 years, comparing delivery at a public/ private health facility versus delivery at home, and timely (0\u0026ndash;3 months) first ANC visit for the last birth tended to lower when women experienced IPV.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study emphasizes the links between social determinants of health, serious problems in accessing healthcare and maternal services, and IPV as a major risk factor. Policymakers should enhance strategies to prevent IPV, which negatively impacts women's health and pregnancies, focusing on disadvantaged women, especially those in rural, low-education, and poorer communities.\u003c/p\u003e","manuscriptTitle":"Beyond Healthcare Access: How Intimate Partner Violence Undermines Uganda's Progress Toward Universal Maternal Health Coverage Through Reduced Maternal Health Service Utilization","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-23 14:34:56","doi":"10.21203/rs.3.rs-8584432/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"236824131790313693335111879867551399658","date":"2026-05-11T13:39:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26482662403164782155798948393838401593","date":"2026-05-08T19:54:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-04T09:00:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308887545761333884300198320997215610978","date":"2026-01-26T19:21:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80880469803177559509925200899384333607","date":"2026-01-22T09:36:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-21T19:33:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-13T05:12:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-13T05:10:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"Contraception and Reproductive Medicine","date":"2026-01-12T17:43:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"contraception-and-reproductive-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"carm","sideBox":"Learn more about [Contraception and Reproductive Medicine](http://contraceptionmedicine.biomedcentral.com)","snPcode":"40834","submissionUrl":"https://submission.nature.com/new-submission/40834/3","title":"Contraception and Reproductive Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0d7e995e-81d0-4ead-a56f-072bbd541349","owner":[],"postedDate":"January 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"236824131790313693335111879867551399658","date":"2026-05-11T13:39:56+00:00","index":95,"fulltext":""},{"type":"reviewerAgreed","content":"26482662403164782155798948393838401593","date":"2026-05-08T19:54:44+00:00","index":92,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-23T14:34:56+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-23 14:34:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8584432","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8584432","identity":"rs-8584432","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}