Sexual & Reproductive Healthcare xxx (2017) xxxxxx

Contents lists available at ScienceDirect

Sexual & Reproductive Healthcare

journal homepage: www.srhcjournal.org

Associations between womens perceptions of domestic violence and

contraceptive use in seven countries in West and Central Africa
Comfort Z. Olorunsaiye a,,1, Larissa Brunner Huber b, Sarah B. Laditka b, Shanti Kulkarni c, A. Suzanne Boyd c
a
Health Services Research Program at the University of North Carolina at Charlotte, 9201 University City Boulevard, Charlotte, NC 28223, United States
b
Department of Public Health Sciences, University of North Carolina at Charlotte, 9201 University City Boulevard, Charlotte, NC 28223, United States
c
School of Social Work, University of North Carolina at Charlotte, 9201 University City Boulevard, Charlotte, NC 28223, United States

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: This study examined associations of womens attitudes toward domestic violence (DV) and
Received 18 May 2016 contraceptive use in West and Central Africa.
Revised 6 October 2016 Study design: We used data from the Multiple Indicator Cluster Surveys for women in seven countries in
Accepted 7 January 2017
West and Central Africa (20092011, n = 80,055).
Available online xxxx
Main outcome measure: We measured contraceptive use as none, traditional, or modern contraceptives.
Main outcome measure: DV approval was measured as no, low, or high tolerance of wife beating.
Keywords:
Multinomial logistic regression estimated odds of using traditional or modern methods versus none,
Contraceptive use
Family planning
adjusting for age, education, wealth, residence, parity, marital structure, spousal age-difference, and reli-
Domestic violence gion.
Intimate partner violence Results: Many women had no or low DV tolerance (41%, 44%, respectively); most used no contraception
Reproductive health (81%). In adjusted results, women with low DV tolerance had lower odds of using traditional contracep-
West and Central Africa tive methods (odds ratio, OR = 0.87; 95% confidence interval, CI: 0.780.98) or modern methods
(OR = 0.86; 95% CI: 0.780.95) compared to women with no tolerance. Women with high DV tolerance
had 28% lower odds of traditional contraceptive use (95% CI: 0.600.90), and 38% lower odds of modern
contraceptive use (95% CI: 0.590.88) compared to women with no tolerance.
Conclusion: The high prevalence of DV approval may threaten the success of programs aimed at improv-
ing womens reproductive health, including contraceptive use.
2017 Elsevier B.V. All rights reserved.

Introduction
Improvements in reproductive health and access to contracep-
tion offer important benefits for individuals, families, and commu-
nities by reducing unwanted pregnancies and the number of
children a woman has, and improving general health and well-
being [1,2]. Furthermore, contraceptive use reduces the number
of high-risk pregnancies, and improves birth spacing, which in turn
improves maternal and child health [1]. By reducing the number of
unintended pregnancies, and increasing the space between preg-
nancies, the total number of children a woman has may be
reduced. Having fewer children may improve the health and well-
being of women as well as their surviving children, and increases
the social capital of communities. Access to contraception also
helps adolescent girls complete school, promotes gender equality,
Corresponding author.
E-mail addresses: cyz.comfort@gmail.com (C.Z. Olorunsaiye), lrhuber@uncc.edu
(L. Brunner Huber), sladitka@uncc.edu (S.B. Laditka), skulkar4@uncc.edu
(S. Kulkarni), sboyd@uncc.edu (A.S. Boyd).
1
At the time of this study.
and reduces poverty [3]. With a total fertility rate of 5.6 births
per woman, the prevalence of any contraceptive use in West and
Central Africa is only 18% [4]. Many studies have examined the role
of individual socioeconomic determinants of contraceptive use;
however, substantial gaps remain in our understanding of the
socio-cultural determinants of contraceptive use.
Gender norms, or culturally acceptable definitions of roles,
behaviors, rights, and opportunities for women and men, have the
potential to limit womens access to and use of health services,
including reproductive health care [5]. Culturally specific gender
norms can often limit womens decision-making autonomy, free-
dom of mobility, household decision making, and spousal commu-
nication [6]. Gender norms can shape and reflect societal conditions
of inequality. For example, one study found that men are prone to
perpetrate violence against women if they felt unable to attain
the socially acceptable standard of a successful man [7]. Such patri-
archal norms promote restrictions in education, use of health care,
employment, and decision-making related to marital relationships
and reproductive choices, and domestic violence (also known as
intimate partner violence, referred to hereafter as domestic

http://dx.doi.org/10.1016/j.srhc.2017.01.003
1877-5756/ 2017 Elsevier B.V. All rights reserved.

Please cite this article in press as: Olorunsaiye CZ et al. Associations between womens perceptions of domestic violence and contraceptive use in seven
countries in West and Central Africa. Sex Reprod Healthc (2017), http://dx.doi.org/10.1016/j.srhc.2017.01.003
2 C.Z. Olorunsaiye et al. / Sexual & Reproductive Healthcare xxx (2017) xxxxxx
violence [DV]) [8,9]. The purpose of this study is to assess the rela-
tionship between gender norms related to womens tolerance of DV
and contraceptive method choice in West and Central Africa.
Study setting
The West and Central Africa region comprises two heteroge-
neous regions of sub-Saharan Africa, with a population of over
410 million in 23 countries [10]. Several countries in the region
have poor indices of many social and health outcomes, including
reproductive health. With an annual growth rate of 2.3% [4], the
population of West and Central Africa is forecasted to reach one
billion in 2050 when 46% of the population will be aged 15
29 years [10]. Several countries in the region have experienced
complex civil conflicts; some are recovering from extended periods
of conflicts. Conflicts generally affect the socioeconomic and cul-
tural environment and include the destruction of health care and
social infrastructures and an increase in the prevalence of physical
and sexual violence against women [2,11]. In addition, many coun-
tries have pervasive cultural norms, some of which create condi-
tions that foster the perpetration and acceptability of DV.
Despite similarities in West and Central Africa, there are impor-
tant differences among countries in the region. For example, some
countries are English speaking (Anglophone) (e.g. Sierra Leone,
Nigeria, Ghana), others are French speaking (Francophone) (e.g.,
Central African Republic [CAR], Democratic Republic of Congo
[DRC], and Chad), or Portuguese (e.g. Cape Verde); these differences
can be traced to the colonial era. Moreover, differences in adminis-
trative styles during colonial rule provide further support for the
variations in the social and economic development of countries in
this region. While the decentralized, indirect British administrative
style fostered ethnic and cultural diversity, the centralized, direct
French rule led to the abolition of most traditional institutions and
the adoption of French beliefs and practices in French colonies
[12]. In particular, the 1920s anti-Contraception Law of France
was widespread among French colonies and favored traditional
methods of contraception (e.g., rhythm, withdrawal, herbs) over
more effective methods available during that period (e.g., dia-
phragm, male condoms), and may contribute to the persistent preva-
lence of traditional contraceptive use in many Francophone
countries [13].
Literature review
The health of women and families is affected by DV in several
important ways. Exposure to DV puts women at increased risk for
poorer physical, mental and reproductive health outcomes [14
16]. Strong positive associations exist between a societys tolerance
of wife beating and more traditional gender values and ideals of
male dominance [17]. Studies also suggest that acceptance of DV
is highly correlated with actual DV experience [1820]. In addition,
in North America and parts of Southern Asia, studies have found that
women who experienced DV were less likely to use contraception
[16,21]. In contrast, in sub-Saharan Africa, research has found that
women who experienced DV were more likely to use contraception
[15], suggesting that the complex relationship between DV and con-
traceptive behavior may in part be mediated by cultural context.
A large proportion of women believe that DV is acceptable
under certain circumstances: going out without permission, argu-
ing with their spouse, neglecting the children, refusing sex with
their spouse, and burning the food [17,20]. Additionally, studies
from sub-Saharan Africa suggest that women have more tolerant
attitudes toward DV than men [20,22]. Being accepting of male
dominance (e.g., tolerance of, or perpetration of DV against
women) is associated with higher desired fertility among women
[23], and men in sub-Saharan Africa [17,24], which could pose a
Please cite this article in press as: Olorunsaiye CZ et al. Associations between womens perceptions of domestic violence and contraceptive use in seven
countries in West and Central Africa. Sex Reprod Healthc (2017), http://dx.doi.org/10.1016/j.srhc.2017.01.003
barrier to contraceptive use. Although it is not clear how desired
fertility relative to attitudes toward DV contributes to contracep-
tive behavior, it is possible that women who are accepting of DV
may be less likely to use contraception, or to choose less effective
methods than those who are unaccepting of DV
Nanda et al. [25] examined associations between gender atti-
tude scales and contraceptive use among 200 female-male couples
in Tanzania. The authors found that women generally had more
gender-inequitable attitudes, including acceptance of wife beating
for any of five hypothetical reasons compared with men: going
out without permission, arguing with spouse, neglecting the chil-
dren, refusing sex with their spouse, and burning the food. They
found an inverse relationship between acceptance of wife beating
and contraceptive use among women, but no association among
men. Do and Kurimoto [26] (used recent data from Ghana, Namibia,
Uganda, and Zambia to examine the association between contra-
ceptive use and six measures of womens empowerment. One of
the measures of womens empowerment was an index of womens
attitudes towards DV. These researchers categorized contraceptive
use as couple methods (e.g., male and female condoms, withdrawal,
abstinence) and female only methods (e.g., oral contraceptives,
injectable, female sterilization). Their findings suggest that women
with non-tolerant attitudes towards DV were more likely to use
couple methods of contraception compared to no method. How-
ever, there was no association between DV tolerance and female
only methods. Similarly, in country-stratified analyses, the associa-
tion between womens attitudes towards DV and contraceptive
method choice was not statistically significant in all countries [26].
Taken as a whole, evidence on the potential influence of DV atti-
tudes on contraceptive use and method choice in sub-Saharan
Africa supports the hypothesis that attitudes that are accepting
of DV limit womens ability to use contraception and their choice
of contraceptive methods. Our study sought to explore this
hypothesis in West and Central Africa, a region characterized by
cultures of male dominance, low contraceptive prevalence, and
high fertility. To our knowledge ours is the first study to assess
womens DV attitudes using a gradient of DV tolerance. Prior stud-
ies have measured DV attitudes as a dichotomous measure or a
count of the number of reasons a woman approves. Examining
DV attitude on a gradient helps identify women who may be at
the highest risk of DV victimization and who, as a result, may be
at risk of contraceptive nonuse, possibly because of the fear of
DV. Ours is also one of a few studies that examined traditional
methods of contraception as a separate category. Most previous
studies have grouped traditional method users with nonusers, or
have considered any contraceptive use (modern and traditional
method use) and nonuse. Our approach is particularly useful in
West and Central Africa because of the high prevalence of tradi-
tional method use. Traditional method users have a need for birth
spacing or limiting, just like modern method users. Thus, it is
important to identify women who are likely to rely upon tradi-
tional methods in order to develop appropriate education and
communication approaches about more effective modern contra-
ceptive methods. With the recent conclusion of the Millennium
Development Goals and the ongoing implementation of the Sus-
tainable Development Goals, findings from this study may inform
programs to improve womens reproductive health care, including
contraceptive use.
Methods
Data source and study sample
Study data were obtained from the fourth phase of the Multiple
Indicator Cluster Survey (MICS) conducted between 2009 and 2011
 C.Z. Olorunsaiye et al. / Sexual & Reproductive Healthcare xxx (2017) xxxxxx
[27]. MICS is an international household survey, developed by the
United Nations Childrens Fund (UNICEF) to monitor conditions of
women and children and progress towards global development
goals. Trained interviewers collect the data using a face-to-face,
paper and pencil method. The survey is described in detail else-
where [27]. Briefly, these data were collected from nationally rep-
resentative samples of the non-institutionalized population using a
multiple stage, stratified cluster sampling approach. An equal
number of households are selected from each cluster on a system-
atic random basis. The surveys are weighted for over- or under-
sampling and non-response. UNICEF develops standard sets of core
questionnaire modules, which are tailored to the context of each
country. Thus, the design and standardized core modules allow
for local, regional, or transnational comparison.
We used data from the household and womens questionnaires
for Central African Republic (CAR), Chad, Democratic Republic of
Congo (DRC), Ghana, Nigeria, Sierra Leone, and Togo. A total of
109,575 women completed the interviews. We calculated response
rates across the seven countries in our study: 98.1% for household
response and 92.6% for womens response. Women were excluded
from the sample if they were pregnant at the time of the interviews
(n = 16,012), trying to get pregnant (n = 1143), or if they had miss-
ing information or dont know on contraceptive use (n = 91) or
attitudes towards wife beating (n = 4156). Thus, the analytic sam-
ple for this study was 80,055 women aged 1549 years.
Outcome measure
The outcome variable was contraceptive method. Based on our
study objective, we decided a priori to code the outcome variable as
a categorical variable, including none, traditional, or modern meth-
ods of contraception. Two survey items on contraceptive use were
used to develop the outcome variable. The first was any contracep-
tive use, referring to self-report of any method of contraception
currently used. The questionnaire asked women if they were doing
anything to delay or avoid a pregnancy. The response options
were: yes and no. Thus, women who answered no formed
the first category of the outcome variable, contraceptive nonuse.
For those women who answered yes, the questionnaire further
inquired about the specific contraceptive methods they were using.
We constructed a categorical outcome variable comprising nonuse,
traditional, and modern methods [28]. Modern methods were male
condom, female condom, diaphragm, foam or jelly, female
sterilization, male sterilization, intrauterine device, injectables,
implants, and oral contraceptives. Traditional methods were
lactational amenorrhea method, periodic abstinence or rhythm,
withdrawal, and others. We conducted a sensitivity analysis
using modern methods as the desired outcome and observed sim-
ilar patterns as those reported. Women with low and high degrees
of DV tolerance had significantly reduced odds of using modern
contraceptive methods, compared to women with no DV tolerance.
Exposure variable
The exposure variable was attitude towards DV. This variable
was constructed using womens responses to the questions in the
DV module that asked if a woman thought a man was justified
(hereafter, approved) for hitting his wife in the following situa-
tions: (1) going out without telling him, (2) neglecting the children,
(3) arguing with him, (4) refusing to have sex with him, and (5)
burning the food. For each item, response options included yes,
no, and dont know. First, we computed a count variable that
included the number of reasons for DV approved by each respon-
dent, ranging from 0 to 5. Next, based on the distribution of this
count variable, we constructed a three-category variable measur-
ing the degree of tolerance of DV: none if no reason was
Please cite this article in press as: Olorunsaiye CZ et al. Associations between womens perceptions of domestic violence and contraceptive use in seven
countries in West and Central Africa. Sex Reprod Healthc (2017), http://dx.doi.org/10.1016/j.srhc.2017.01.003
3
approved, low if 14 reasons were approved, and high if all five
reasons were approved. We also conducted a sensitivity analysis
using an alternative distribution of the categorical variable
(0 = none, 13 = low, and 45 = high); we found that the directions
and significance of the associations did not differ meaningfully
from those reported.
Control variables
Consistent with related research we included the following
covariates: womens age (1524, 2534, or 3549 years), educa-
tion (none, primary, or secondary/higher), parity (0, 12, 34,
or > 4), marital status (currently married or never/previously mar-
ried), husbands/partners education, age, and spousal age differ-
ence (i.e., <10 years or P10 years) [2931]. Other covariates were
household wealth index (in quintiles), and religion (Christian, Mus-
lim, others), desired future birth (yes, no, or dont know), area of
residence (rural or urban) and marital structure (monogamous or
polygamous) [29,31].
Statistical analysis
Descriptive statistics including means, frequencies, and bivari-
ate statistics were calculated. We used multinomial logistic regres-
sion to obtain odds ratios (ORs) and 95% confidence intervals (CIs)
of the association between attitudes towards DV and contraceptive
use. We identified potential confounders by adding each covariate
to regression models of DV tolerance and contraceptive method
choice. If the covariate caused the magnitude of the OR to change
by 10% or more, we retained that variable in the adjusted model
[32]. Thus, we adjusted for womens age, womens education,
household wealth, area of residence, marital structure, religion,
parity, and spousal age difference in the multivariate models. In
a separate adjusted analysis, we stratified by country to examine
if there were differences in womens contraceptive behaviors
among countries. To account for the complex sampling design used
by MICS, we conducted the analysis using SAS-callable SUDAAN
(NC, Research Triangle Institute). The Institutional Review Board
(IRB) of [our institution] approved our study protocol. UNICEF
approved the use of the datasets.
Results
Characteristics of the sample
This study included 80,055 women from seven countries in
West and Central Africa (CAR: n = 9014, Chad: n = 10,703, DRC:
n = 9393, Ghana: n = 9312, Nigeria: n = 24,941, Sierra Leone:
n = 11,221, and Togo: n = 5446 women). About 20% of women in
the sample reported using contraception: 12.7% reported using
modern methods, and 6.6% reported traditional contraceptive use
(Table 1). About 60% of women approved of wife beating for at
least one of the five reasons. The reason for wife beating most com-
monly approved was for neglecting the children (44.1%); the least
approved reason was for burning the food (27.2%) (results not
shown in tables). Nearly 15% of women approved all five reasons
for wife beating by a spouse. Among women who used modern
contraceptive methods, about half (48%) had no tolerance for DV,
compared to traditional method users and nonusers, many of
whom had low tolerance for DV (46% and 44% respectively).
4 C.Z. Olorunsaiye et al. / Sexual & Reproductive Healthcare xxx (2017) xxxxxx

Table 1
Characteristics of West and Central African Women by Contraceptive Behavior, Multiple Indicator Cluster Survey; 20092011.

Characteristic Total Contraceptive use n (%) P-value

a b
Nonuse Traditional Modern
80,055 65,495 (80.7) 5176 (6.6) 9384 (12.7)
DV tolerancec <0.001
None 30,974 (40.6) 24,707 (39.3) 2104 (42.5) 4163 (48.0)
Low (some) 36,521 (44.3) 29,837 (44.5) 2414 (45.7) 4270 (42.6)
High (all) 12,560 (15.0) 10,951 (16.2) 658 (11.7) 951 (9.5)
Maternal age <0.001
1524 29,454 (36.5) 24,783 (37.8) 1561 (29.1) 3110 (32.6)
2534 25,677 (32.7) 20,309 (31.2) 1979 (39.8) 3389 (38.2)
3549 24,924 (30.8) 20,403 (31.0) 1636 (31.2) 2885 (29.2)
Marital status <0.001
Currently married 55,276 (68.4) 45,126 (68.3) 4141 (79.4) 6009 (64.0)
Never/ previously married 24,779 (31.6) 20,369 (31.8) 1035 (20.6) 3375 (36.0)
Womens education <0.001
None 33,695 (38.2) 30,329 (42.8) 1448 (23.3) 1918 (16.6)
Primary 21,897 (28.5) 17,534 (27.8) 1659 (33.3) 2704 (30.0)
PSecondary 24,458 (33.4) 17,628 (29.4) 2069 (43.4) 4761 (53.4)
Parity <0.001
0 18,753 (24.0) 15,700 (24.5) 731 (15.0) 2322 (25.4)
12 18,995 (24.4) 15,372 (24.0) 1332 (26.6) 2291 (25.8)
34 16,622 (21.3) 13,250 (20.6) 1248 (25.4) 2124 (23.5)
>4 25,685 (30.3) 21,173 (30.9) 1865 (33.0) 2647 (25.3)
Area of residence <0.001
Urban 28,496 (38.8) 21,959 (35.7) 1910 (40.9) 4627 (57.7)
Rural 51,559 (61.2) 43,536 (64.3) 3266 (59.1) 4757 (42.3)
Wealth quintile <0.001
Poorest 17,119 (17.7) 15,097 (19.5) 997 (16.0) 1025 (7.1)
Poor 15,787 (18.2) 13,548 (19.5) 924 (15.7) 1315 (11.3)
Middle 15,487 (19.4) 12,752 (19.8) 1009 (19.2) 1726 (17.0)
Rich 15,588 (20.8) 12,219 (20.1) 1066 (20.7) 2303 (25.7)
Richest 16,074 (23.9) 11,879 (21.2) 1180 (28.4) 3.015 (38.9)
Desire future birth <0.001
Yes 54,541 (67.8) 45,688 (69.6) 3364 (63.9) 5489 (58.3)
No 16,375 (20.8) 12,643 (19.6) 1303 (26.7) 2429 (25.9)
Unsure/dont know 9139 (11.4) 7164 (10.8) 509 (9.4) 1466 (15.8)
Marital structure <0.001
Polygamous 18,441 (21.4) 15,943 (23.0) 1050 (17.0) 1448 (13.9)
Monogamous 36,289 (46.3) 28,768 (44.6) 3022 (61.0) 4499 (49.4)
Missing 25,325 (32.3) 20,784 (32.4) 1104 (22.0) 3437 (36.7)
Spouses education <0.001
None 29,269 (36.3) 24,645 (37.5) 1537 (29.4) 3087 (32.6)
Primary 19,81 (26.3) 15,917 (25.8) 1579 (32.5) 2318 (26.3)
PSecondary 23,004 (29.5) 18,372 (28.8) 1721 (32.6) 2911 (32.0)
Unknown/ missing 7968 (8.0) 6561 (8.0) 339 (5.5) 1068 (9.1)
Religion <0.001
Muslim 20,986 (23.5) 18,830 (26.2) 859 (12.8) 1297 (12.0)
Christian 38,674 (51.5) 29,763 (48.2) 3819 (77.9) 5092 (58.6)
Others/unknown 3728 (4.3) 3070 (4.3) 284 (5.1) 374 (3.5)
Missing 16,667 (20.7) 13,832 (21.2) 214 (4.3) 2621 (25.9)
Mean age at first marital union 17.85 17.61 18.91 18.88 <0.001
Mean age (women) 29.1 28.9 30.0 29.4 0.003
Mean age of spouse 45.7 46.3 42.9 43.4 <0.001
Spousal age difference 14.2 14.9 11.4 11.0 <0.001
Country <0.001
CARd 9041 (11.3) 7726 (11.6) 632 (11.6) 683 (9.7)
Chad 10,703 (13.4) 9992 (15.6) 479 (7.6) 232 (2.5)
DRCe 9393 (11.7) 7363 (11.2) 1288 (24.3) 740 (6.1)
Ghana 9312 (11.7) 6722 (9.7) 716 (16.9) 1874 (21.4)
Nigeria 24,941 (31.2) 19,860 (30.5) 1847 (35.4) 3234 (34.5)
Sierra Leone 11,221 (13.9) 9264 (14.3) 124 (2.4) 1833 (17.9)
Togo 5446 (6.8) 4568 (7.0) 90 (1.9) 788 (7.93)
a
Traditional methods include: lactational amenorrhea method, periodic abstinence/rhythm, and withdrawal.
b
Modern methods include: male condom, female condom, diaphragm, foam/jelly, female sterilization, male sterilization, intrauterine device, injectables, implants, and the
pill.
c
DV = domestic violence.
d
CAR = Central African Republic.
e
DRC = Democratic Republic of Congo.

Please cite this article in press as: Olorunsaiye CZ et al. Associations between womens perceptions of domestic violence and contraceptive use in seven
countries in West and Central Africa. Sex Reprod Healthc (2017), http://dx.doi.org/10.1016/j.srhc.2017.01.003
 C.Z. Olorunsaiye et al. / Sexual & Reproductive Healthcare xxx (2017) xxxxxx
Unadjusted associations between womens tolerance of DV and
contraceptive method
There was no significant association between low levels of tol-
erance of DV and traditional method use (OR 0.95; 95% CI: 0.85,
1.05) (Table 2). However, women with low levels of DV tolerance
had 22% lower odds of modern method use compared to women
who were not tolerant of DV (OR 0.78; 95% CI: 0.73, 0.84). Com-
pared to women with no DV tolerance, women with high DV toler-
ance were less likely to use traditional methods of contraception
(OR 0.68; 95% CI: 0.56, 082) or modern methods of contraception
(OR 0.48; 95% CI: 0.42, 0.54).
Adjusted associations between womens tolerance of DV and
contraceptive use
In adjusted results, the association between low tolerance of DV
and traditional method use was attenuated (OR 0.87; 95% CI: 0.78,
0.98) (Table 2). However, the association between high tolerance of
DV and traditional contraceptive method use was largely
unchanged (OR 0.72; 95% CI: 0.60, 0.90). The association between
low tolerance for DV and modern contraceptive use was attenu-
ated (OR 0.86; 95% CI: 0.78, 0.95) as was the association between
high DV tolerance and modern contraceptive use (OR 0.62; 95%
CI: 0.59, 0.88).
Adjusted associations between womens tolerance of DV and
contraceptive use by country
In stratified analysis, the results indicated that DV-
contraceptive use associations differed among countries (Test of
Homogeneity p-value < 0.001; Table 3). There was no association
between low tolerance of DV and traditional method use among
all seven countries. Among women in six countries, there was no
association between high tolerance of DV and traditional method
use. However, there was a statistically significant association
between high tolerance of DV and traditional method use among
women in Nigeria (OR 0.40; 95% CI: 0.28, 0.57). There were no sta-
tistically significant associations between low and high DV toler-
ance and modern contraceptive use among all countries.
Discussion
This study examined associations between womens attitudes
toward DV and contraceptive use among women from seven West
and Central African countries. The results highlight low levels of
contraceptive use across the seven countries. Our study extends
research in the area of womens reproductive health by assessing
attitudes toward DV on a gradient to help identify women who
experience DV as a barrier or limitation to contraceptive use. Con-
sistent with our expectation, in pooled, adjusted multinomial
regression models, women who were more tolerant of DV had
lower odds of using traditional or modern contraceptive methods
compared to women who were intolerant of DV. As the degree of
tolerance of DV increased from none to low, and low to high, the
odds of using traditional or modern contraceptive methods
decreased. The magnitude of the differences between low and high
degrees of tolerance of DV was larger for modern contraceptive
methods than traditional methods. The results also suggest that
the largest changes in the odds of traditional or modern contracep-
tive use, respectively, were among women with high tolerance of
DV. However, women with low tolerance did not differ much from
those women who were intolerant in terms of contraceptive
method choice.
Please cite this article in press as: Olorunsaiye CZ et al. Associations between womens perceptions of domestic violence and contraceptive use in seven
countries in West and Central Africa. Sex Reprod Healthc (2017), http://dx.doi.org/10.1016/j.srhc.2017.01.003
5
The Test of Homogeneity for our stratified analysis was statisti-
cally significant. Although there was a statistically significant asso-
ciation between high tolerance of DV and traditional method use
among women in Nigeria, this association was not present among
women in the other studied countries. Nonetheless, results from
the present study contribute to the literature on contraceptive
use in West and Central Africa. The results suggest that womens
tolerance of DV may be associated with a reduced likelihood of
contraceptive use. These findings also suggest that women with
high levels of DV tolerance may be at increased risk of contracep-
tive nonuse or use of less effective contraceptive methods com-
pared to women with low levels or no tolerance of DV.
The results of the present study are consistent with those of a
recent study from Tanzania, in which the authors used an index
measure of womens attitudes towards wife beating in conjunction
with other measures of gender equity [25]. Lower levels of contra-
ceptive use among women who are more accepting of DV may be
related to womens socioeconomic characteristics, and couples
relationship dynamics, which could affect reproductive decision-
making. These factors may be important barriers to access to
reproductive health care, which contribute to a lower likelihood
of using any method of contraception. It is also possible that
women with higher levels of DV tolerance may have less access
to modern contraception, and thus may be more likely to choose
traditional or no method of contraception as we observed in the
adjusted regression model of the pooled data.
The significant Test of Homogeneity suggests that there are dif-
ferences in the DV tolerance-contraceptive use relationship among
countries. While there were no associations between DV tolerance
and modern contraceptive use among women in each country,
there was a difference for the high DV tolerance-traditional contra-
ceptive use association. In particular, among women in Nigeria,
high DV tolerance was significantly associated with reduced odds
of traditional contraceptive use. Large samples may help to confirm
this finding in Nigeria and other countries. It is also possible that
more sensitive and culturally appropriate measures of DV toler-
ance may be needed in sub-Saharan Africa.
We acknowledge study limitations. DV tolerance may be under-
reported: the surveys are interviewer administered and women
may have given socially desirable responses. The questions asked
about approval of wife beating assess attitudes, and not actual
DV experience, which may be associated with greater stigma than
DV tolerance. To the extent that DV tolerance may be underre-
ported, our results are likely to understate associations between
tolerance of DV and contraceptive use. The emphasis on attitudes
rather than actual DV experience may have reduced some of the
bias related to under-reporting. This study was limited to the ques-
tions asked on the MICS survey. For example, the surveys did not
include questions about DV experience. It is possible that womens
contraceptive behaviors would differ from the present findings rel-
ative to actual experiences of DV. It is likely that married and or
cohabiting women, when faced with DV experience, may be more
motivated to prevent pregnancy, and thus be more willing to use
contraception, compared to unmarried women. In addition, we
could not account for womens decision-making autonomy, which
may also be an important consideration in contraceptive decision-
making. Finally, our study sample was from seven countries in
West and Central Africa; thus, our findings may not be generaliz-
able to other countries.
Our study also has several strengths. Classifying contraceptive
methods as either traditional or modern methods is useful. While
the overall goal of reproductive health-related development pro-
grams is to increase the use of more effective and modern contra-
ception, the reality is that traditional methods are widely used in
sub-Saharan Africa, where contraceptive acceptance is low and
family planning programs are weak [33]. Women who use
6 C.Z. Olorunsaiye et al. / Sexual & Reproductive Healthcare xxx (2017) xxxxxx

Table 2
Unadjusted and Adjusted Odds Ratios of Contraceptive Use by Demographic Characteristics of Women in West and Central Africa, Multiple Indicator Cluster Survey; 20092011.

Characteristic Unadjusted odds ratios and 95% confidence Adjusted odds ratios and 95% confidence intervals
intervals of contraceptive use of contraceptive use
Traditionala Modernb Traditionala Modernb
c
Degree of DV tolerance
None 1.00 1.00 1.00 1.00
Low 0.95 (0.851.05) 0.78 (0.730.84) 0.87 (0.780.98)* 0.86 (0.780.95)*
High 0.68 (0.560.82) 0.48 (0.420.54) 0.72 (0.600.90)y 0.62 (0.590.88)
Maternal age
1524 1.00 1.00 1.00 1.00
2534 1.66 (1.501.83) 1.42 (1.321.53) 1.15 (1.021.30)* 1.41 (1.291.54)
3549 1.31 (1.171.45) 1.09 (1.001.18)* 0.76 (0.660.88) 0.91 (0.811.01)
Marital status
Currently married 1.00 1.00 1.00 1.00
Previously/Never married 0.56 (0.500.62) 1.21 (1.121.31) 0.50 (0.430.57) 0.89 (0.810.97)*
Womens education
None 1.00 1.00 1.00 1.00
Primary 2.20 (1.952.47) 2.78 (2.533.06) 2.11 (1.872.37) 2.03 (1.842.23)
PSecondary 2.71 (2.383.09) 4.67 (4.255.14) 3.24 (2.833.72) 2.96 (2.663.30)
Parity
0 1.00 1.00 1.00 1.00
12 1.81 (1.592.06) 1.04 (0.951.14) 1.52 (1.311.76) 1.32 (1.191.47)
34 2.01 (1.742.31) 1.10 (0.991.22) 1.81 (1.522.15) 1.44 (1.271.64)
>4 1.74 (1.531.98) 0.79 (0.720.87) 1.98 (1.642.38) 1.36 (1.181.56)
Area of residence
Urban 1.00 1.00 1.00 1.00
Rural 0.80 (0.700.91)y 0.41 (0.370.45) 1.05 (0.901.22) 0.73 (0.660.81)
Wealth quintile
Poorest 1.00 1.00 1.00 1.00
Poor 0.98 (0.851.14) 1.57 (1.391.78) 0.87 (0.751.00)* 1.33 (1.181.51)
Middle 1.18 (1.011.38)* 2.34 (2.062.67) 0.91 (0.781.07) 1.60 (1.411.82)
Rich 1.26 (1.071.48)y 3.49 (3.064.00) 0.87 (0.741.03) 1.90 (1.652.18)
Richest 1.63 (1.381.94) 5.02 (4.395.73) 1.01 (0.841.23) 2.11 (1.812.45)
Desire for future birth
Yes 1.00 1.00 1.00 1.00
No 1.48 (1.351.63) 1.58 (1.461.72) 1.32 (1.181.47) 1.67 (1.521.84)
Unsure/dont know 0.95 (0.821.09) 1.74 (1.561.94) 1.06 (0.921.23) 1.97 (1.762.21)
Marriage structured
Polygamous 1.00 1.00
Monogamous 1.84 (1.662.05) 1.83 (1.662.01)
Missing 0.91 (0.791.04) 1.87 (1.672.08)
Spouses educationd
None 1.00 1.00
Primary 1.12 (0.871.44) 0.98 (0.821.16)
PSecondary 0.88 (0.631.23) 1.03 (0.811.29)
Religion
Christian 1.00 1.00 1.00 1.00
Muslim 0.30 (0.260.35) 0.38 (0.330.43) 0.35 (0.300.43) 0.61 (0.540.68)
Other/ Unknown 0.72 (0.590.88)y 0.67 (0.560.80) 0.85 (0.691.04) 1.07 (0.901.27)
Mean age at first marriage/uniond 1.06 (1.051.07) 1.06 (1.041.07)
Spousal age difference 0.99 (0.980.99) 0.99 (0.980.99) 0.84 (0.760.93)y 0.73 (0.670.79)
a
Traditional methods include: lactational amenorrhea method, periodic abstinence/rhythm, and withdrawal.
b
Modern methods include: male condom, female condom, diaphragm, foam/jelly, female sterilization, male sterilization, intrauterine device, injectables, implants, and the
pill.
c
DV = domestic violence
d
Omitted from adjusted model due to collinearity.
*
p < 0.05.
y
p < 0.01.

p < 0.001.

traditional contraceptive methods have a need to delay or limit
child bearing, and may benefit from focused education about more
effective modern methods for their fertility intentions. Thus, it is
helpful to understand the socio-cultural profile of women who rely
on traditional methods as well as those who use modern contra-
ceptives. Such information may be useful for developing educa-
tional messages and programs for women who use traditional
methods with the aim of promoting modern methods as more
effective and reliable options for birth spacing and limiting.
The analysis of recent, transnational data is another strength.
Countries in West and Central Africa have much in common.
The region faces daunting crosscutting challenges because of
pervasive poverty, natural disasters, and civil and political con-
flicts. Conflicts and civil unrest generally have devastating
effects on health systems and the status of women, possibly
contributing to the poor reproductive health indices. Thus, this
study adds to the existing literature in this relatively under-
studied area.

Please cite this article in press as: Olorunsaiye CZ et al. Associations between womens perceptions of domestic violence and contraceptive use in seven
countries in West and Central Africa. Sex Reprod Healthc (2017), http://dx.doi.org/10.1016/j.srhc.2017.01.003
 C.Z. Olorunsaiye et al. / Sexual & Reproductive Healthcare xxx (2017) xxxxxx 7

Table 3
Adjusted Odds Ratios and 95% Confidence Intervals of Contraceptive Use among Women in West and Central Africa by Country, Multiple Indicator Cluster Survey; 20092011.

Contraceptive Method
Traditionala Modernb
c d
Country Degree of DV Tolerance
None Low High None Low High
OR OR (95% CI) OR (95% CI) OR OR (95% CI) OR (95% CI)
CARe 1.00 1.05 (0.771.44) 1.02 (0.671.55) 1.00 1.18 (0.861.61) 1.50 (0.992.29)
Chad 1.00 1.17 (0.701.94) 0.87 (0.501.53) 1.00 0.94 (0.601.48) 1.24 (0.762.04)
DRCf 1.00 1.10 (0.841.43) 1.36 (0.922.01) 1.00 0.99 (0.721.37) 0.92 (0.611.39)
Ghana 1.00 0.95 (0.721.25) 0.97 (0.551.70) 1.00 1.07 (0.891.29) 1.01 (0.631.62)
Nigeria 1.00 0.87 (0.741.01) 0.40 (0.280.57) 1.00 0.92 (0.801.08) 1.03 (0.791.34)
Sierra Leone 1.00 1.38 (0.832.28) 0.51 (0.201.31) 1.00 0.91 (0.721.14) 0.97 (0.741.27)
Togo 1.00 1.15 (0.691.91) 0.64 (0.133.29) 1.00 1.18 (0.971.45) 0.81 (0.451.46)
a
Traditional methods include: lactational amenorrhea method, periodic abstinence/rhythm, and withdrawal.
b
Modern methods include: male condom, female condom, diaphragm, foam/jelly, female sterilization, male sterilization, intrauterine device, injectables, implants, and the
pill.
c
Test of homogeneity: Chi square = 6123.12, p < 0.001.
d
DV = domestic violence.
e
CAR = Central African Republic.
f
DRC = Democratic Republic of Congo.

p < 0.001.

Implications for policy, practice and research
The results provide useful insights to address low rates of con-
traceptive uptake and use. The high prevalence of approval of DV
by women in these countries presents a threat to the success of
programs aimed at eliminating DV against women, and improving
womens reproductive health. Only 40% of women reported intol-
erance of DV for any of the five reasons. Given the strong correla-
tion between DV attitudes and victimization [19], it is important
for programs that address violence against women to focus not
only on mens attitudes, but also on womens attitudes towards
DV to help reduce the intergenerational transmission of attitudes
that promote acceptance of DV. Educational programs involving
girls, women and men may be especially helpful.
While the goal of population policies is to increase the preva-
lence of modern contraceptive use for birth spacing and birth lim-
iting, it is useful to pay special attention to norms and values that
threaten a womans perceived self-efficacy. The fear of DV for any
reason is an important barrier to contraceptive use. It would be
useful for family planning providers to screen women for their
DV attitudes to identify those at increased risk of DV and or contra-
ceptive nonuse or traditional method use. Women who use tradi-
tional methods may have a need for birth spacing or limiting, but
may lack the self-efficacy to use modern methods. Education is
associated with health literacy and the ability to understand and
follow health information, and self-efficacy [34,35]. Countries in
West and Central Africa should encourage female education by
adopting policies that promote the enrollment and retention of
girls in school. Not only does this action have the potential to
increase self-efficacy, it also has the potential to increase economic
capital.
There are several possible pathways to contraceptive decision-
making. Womens attitudes about gender norms are one pathway.
Few studies have explored whether the association between
womens tolerance of DV and contraceptive method use differs
by country. Results have been inconsistent and call for further
research into other decision making pathways to contraceptive
behavior among countries. It may be useful to examine female
dependent versus couple dependent contraceptive methods as
possible classifications of contraceptive methods.
Additional research exploring alternative categories of DV toler-
ance may also be beneficial for understanding womens attitudes
towards DV. In another area, many issues related to gender norms
and values may be more difficult to measure and examine quanti-
tatively. Thus, future research on womens attitudes towards DV
and contraceptive behavior would benefit from qualitative and
mixed methods approaches. Results from focus groups could help
us to understand why women perceive wife beating to be accept-
able in certain scenarios and not in others, while also shedding
light on nuanced relationships, if any, between DV tolerance and
contraceptive decision-making.
References
[1] Cleland J, Conde-Agudel A, Peterson H, Ross J, Tsui A. Contraception and health.
The Lancet 2012;380(9837):14956. http://dx.doi.org/10.1016/S0140-6736
(12)60609-6.
[2] Kinney MV, Kerber KJ, Black RE, Cohen B, Nkrumah F, Coovadia H, et al. Sub-
Saharan Africas mothers, newborns, and children: where and why do they
die? PLoS Med 2010;7(6):19. http://dx.doi.org/10.1371/journal.
pmed.1000294.
[3] United Nations Population Fund. State of the World Population, 2012: By
choice, not by chance: Family Planning, Human Rights and Development. New
York: The United Nations Population Fund; 2013. Available at: <http://www.
unfpa.org/webdav/site/global/shared/swp/2012/EN_SWOP2012_Report.pdf>
[Accessed October 23, 2014].
[4] UNICEF. The State of the Worlds Children 2015: Reimagine the future:
Innovation for every child. New York: The United Nations Childrens Fund;
2014. Available at: <http://sowc2015.unicef.org/> [Accessed September 5,
2015].
[5] Rottach E, Schuler SR, Hardee K. Gender perspectives improve reproductive
outcomes: new evidence. Washington, DC: Population Reference Bureau;
2009.
[6] Gage Anastasia J. Womens socioeconomic position and contraceptive behavior
in Togo. Stud Fam Plann 1995:26477.
[7] Olayanju L et al. Combating intimate partner violence in Africa: opportunities
and challenges in five African countries. Aggression Violent Behav 2013;18
(1):10112.
[8] United Nations Population Fund (UNFPA). Gender equality: a cornerstone of
development. New York; 2011. Available from: <http://www.unfpa.
org/gender/>. [Accessed January 16, 2015].
[9] Kishor SA. Focus on gender: collected papers on gender using DHS
data. Calverton, MD: ORC Macro; 2005.
[10] United Nations Population Fund. Our Region: West and Central Africa at a
glance. n.d. Available at: <https://wcaro.unfpa.org/public/cache/offonce/pid/
14497;jsessionid=234D36804AF8801BE8B05D0E99FB1D97.jahia01>.
[Accessed May 13, 2015].
[11] Horn R, Puffer ES, Roesch E, Lehmann H. Womens perceptions of effects of war
on intimate partner violence and gender roles in two post-conflict West
African Countries: consequences and unexpected opportunities. Confl Health
2014:812. http://dx.doi.org/10.1186/1752-1505-8-12.
[12] Griffiths I. The Scramble for Africa: inherited political boundaries. Geograph. J.
1986;152(2):20416. http://dx.doi.org/10.2307/634762.
[13] Wolf B. Anti-contraception laws in Sub-Saharan Francophone Africa: sources
and ramifications. Fletcher School of Law and Diplomacy, Tufts University;
1973.
[14] Plichta SB. Intimate partner violence and physical health consequences, policy
and practice implications. J. Interpersonal Violence 2004;19(11):1296323.

Please cite this article in press as: Olorunsaiye CZ et al. Associations between womens perceptions of domestic violence and contraceptive use in seven
countries in West and Central Africa. Sex Reprod Healthc (2017), http://dx.doi.org/10.1016/j.srhc.2017.01.003
8 C.Z. Olorunsaiye et al. / Sexual & Reproductive Healthcare xxx (2017) xxxxxx
[15] Alio AP, Daley EM, Nana PN, Duan J, Salihu HM. Intimate partner violence and
contraception use among women in Sub-Saharan Africa. Int. J. Gynecol. Obstet.
2009;107(1):358.
[16] Williams CM, Larsen U, McCloskey LA. Intimate partner violence and womens
contraceptive use. Violence Against Women 2008;14(12):138296.
[17] Oyediran KA, Isiugo-Abanihe UC. Perceptions of Nigerian women on domestic
violence: evidence from 2003 Nigeria Demographic and Health Survey. Afric J
Reprod Health/La Revue Africaine de la Sant Reproductive 2005;9(2):3853.
[18] Rahman M, Nakamura K, Seino K, Kizuki M. Does gender inequity increase the
risk of intimate partner violence among women? Evidence from a national
Bangladeshi sample. PLoS ONE 2013;8(12):e8242334.
[19] Faramarzi M, Esmailzadeh S, Mosavi S. A comparison of abused and non-
abused womens definitions of domestic violence and attitudes to acceptance
of male dominance. Europ J Obst Gynecol Reprod Biol 2005;122(2):22531.
[20] Koenig MA et al. Domestic violence in rural Uganda: evidence from a
community-based study. Bull World Health Organ 2003;81(1):5360.
[21] Heise L, Ellsberg M, Gottmoeller M. A global overview of gender-based
violence. Int J Gynecol Obst 2002;78:S5S14.
[22] Speizer IS. Intimate partner violence attitudes and experience among women
and men in Uganda. J Interpersonal Viol 2010;25(7):122441.
[23] Upadhyay UD, Karasek D. Womens empowerment and achievement of
desired fertility in Sub-Saharan Africa. DHS Working Paper No. 80. ICF
Macro, Calverton, MD; 2010.
[24] Snow RC, Winter RA, Harlow SD. Gender attitudes and fertility aspirations
among young men in five high fertility East African countries. Stud Fam Plann
2013;44(1):124.
[25] Nanda Geeta, Schuler Sidney Ruth, Lenzi Rachel. The influence of gender
attitudes on contraceptive use in Tanzania: new evidence using husbands and
wives survey data. J Biosoc Sci 2013;45(03):33144.
Please cite this article in press as: Olorunsaiye CZ et al. Associations between womens perceptions of domestic violence and contraceptive use in seven
countries in West and Central Africa. Sex Reprod Healthc (2017), http://dx.doi.org/10.1016/j.srhc.2017.01.003
[26] Mai Do, Kurimoto Nami. Womens empowerment and choice of contraceptive
methods in selected African countries.. Int. Perspect. Sexual Reprod. Health
2012:2333.
[27] UNICEF. ChildInfo: Monitoring the situation of children and women: Multiple
Indicator Cluster Surveys. n.d. Available at: <http://www.childinfo.org/mics.
html>, [Accessed January 3, 2013].
[28] United Nations. Millennium development goals indicators: official list of MDG
indicators. New York: United Nations; 2008. Available at: <http://mdgs.un.org/
unsd/mdg/host.aspx?Content=indicators/officiallist.htm> [Accessed December
18, 2014].
[29] Corroon M, Speizer IS, Fotso J-C, Akiode A, Saad A, Calhoun L, et al. The role of
gender empowerment on reproductive health outcomes in urban Nigeria.
Matern Child Health J 2013;19.
[30] Addai I. Does religion matter in contraceptive use among Ghanaian women?
Rev Religious Res 1999:25977.
[31] Stephenson R, Koenig MA, Acharya R, Roy TK. Domestic violence, contraceptive
use, and unwanted pregnancy in rural India. Stud Fam Plann 2008;39
(3):17786.
[32] Maldonado G, Greenland S. Simulation study of confounder-selection
strategies. Am J Epidemiol 1993;138(11):92336.
[33] Creanga AA, Gillespie, Karklins S, Tsui AO. Low use of contraception among
poor women in Africa: an equity issue. Bull World Health Organ 2011;89
(4):25866.
[34] Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health
literacy and health outcomes: an updated systematic review. Ann Intern Med
2011;155(2):97107.
[35] Bandura A. Self-efficacy: toward a unifying theory of behavioral change.
Psychol Rev 1977;84(2):1917.