literature review of marital violence

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Intimate partner violence: a literature review, article information.

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Background:

Intimate Partner Violence (IPV) is a complex issue that appears to be more prevalent in developing nations. Many factors contribute to this problem.

This article aimed to review and synthesize available knowledge on the subject of Intimate Partner Violence. It provides specific information that fills the knowledge gap noted in more global reports by the World Health Organization.

A literature search was conducted in English and Spanish in EBSCO and Scopus and included the keywords “Intimate, Partner, Violence, IPV.” The articles included in this review cover the results of empirical studies published from 2004 to 2020.

The results show that IPV is associated with cultural, socioeconomic, and educational influences. Childhood experiences also appear to contribute to the development of this problem.

Conclusion:

Only a few studies are focusing on empirically validated interventions to solve IPV. Well-implemented cultural change strategies appear to be a solution to the problem of IPV. Future research should focus on examining the results of strategies or interventions aimed to solve the problem of IPV.

1. INTRODUCTION

Intimate Partner Violence (IPV) is the most prevalent type of violence against women worldwide. It is defined as a “behavior by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse, and controlling behaviors” [ 1 ]. The United Nations has defined violence against women as “any act of gender-based violence that results in or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life” [ 2 ].

The percentage of women experiencing violence in various parts of the world has been recorded. Different factors appear to influence the incidence of this worldwide problem. However, there are no single studies that summarize findings on the subject. The aim of this article was to review available knowledge regarding Intimate Partner Violence. There is a need to understand this problem so that viable solutions and or preventive measures could be implemented.

2. METHODOLOGY

2.1. searching strategy.

The literature search was conducted in English and Spanish using EBSCO (Psychology and Behavioral Sciences Collection, Academic Search Premier, and Fuente Academica Premiere) and Scopus. It included the keywords “Intimate, Partner, Violence, IPV” and thematic issues on the subject, such as “depression, anxiety, body, ache.” Only the findings of empirical studies were considered. The articles ranged from 2004 to 2020. The analysis of full texts of articles was carried out several times and data were extracted according to the aim of this study.

3.1. Percentage of Women Experiencing Violence

Data presented by Women UN (2019) indicates that approximately 35 percent of women worldwide have experienced some form of violence in their lifetime [ 3 ]. One-third of women worldwide who have ever been involved in a relationship have experienced physical or sexual violence inflicted by an intimate partner [ 4 ].

With a focus on the Americas, the percentage of women who have experienced physical or sexual IPV in the past 12 months progressively increases as one examines data from North, Central and South America (1.1% in Canada, 6.6% in the United States, 7.8% in Costa Rica, and 27.1% in Bolivia) [ 5 ]. Compared to countries in Central and South America, Bolivia reports the highest percentage (52.3%) of women ever experiencing physical violence by an intimate partner. However, the percentage of women reporting ever experiencing sexual violence by an intimate partner was similar across nations ( i.e. , Bolivia 15.2%, Nicaragua 13.1%, Guatemala 12.3%, Colombia 11.8%, Ecuador 11.5%, El Salvador 11.5%, Haiti 10.8%, and Peru 9.4%). Moreover, the percentage of women who reported ever experiencing IPV in the form of emotional abuse (insults, humiliation, intimidation, and threats of harm) also occurred relatively equally across nations ( e.g. , Nicaragua 47.8%, El Salvador 44.2%, Guatemala 42.2%, Colombia, 41.5%, Ecuador 40.7%), with a few exceptions (Haiti 17.0%, Dominican Republic 26.1%) [ 6 ].

Data from Colombia indicates that 31.1% of women in that country reported experiencing economic or patrimonial violence from an intimate partner, 7.6% experienced IPV in the form of sexual violence, and 64% experienced psychological violence from a partner [ 7 ]. Similar numbers have been recorded in Ecuador. The National Institute of Statistics and Censuses (INEC 2019) notes that 43 out of 100 women in the country have experienced some form of IPV. Of this group, 40.8% of women reported experiencing psychological violence ( e.g. , humiliation, insults, being threatened with a weapon), 25% said they were victims of physical violence and 8.3% were victims of sexual violence [ 8 ].

3.2. Social Norms and Sociodemographic Factors

Women must contend with societal norms related to domestic violence. For example, in some countries, male dominance or patriarchal systems in which the wife is considered a possession or property of the husband are considered the societal norm. Some studies have shown that social attitudes justifying and or accepting IPV in some developing nations or specific localities increase the incidence of this problem in those areas. Women in these places are likely more tolerant of this problem if it were to happen to them and are less likely to leave a violent relationship [ 9 - 12 ]. Likewise, exposure to violence perpetrated by political groups ( e.g. , police, armed forces) also seems to increase the prevalence of IPV in nations [ 13 - 15 ].

Sociodemographic factors also appear to affect the prevalence of IPV. Studies around the globe indicate that a low level of education in women may put them at a higher risk for IPV [ 16 - 19 ]. This low level of educational attainment could be related to existent socioeconomic disadvantages, a culturally upheld belief that women do not need education because their assigned role is to stay at home and take care of household duties, including the raising of children, and a lack of a network of support that could potentially encourage their educational advancement. For example, a recent study suggested that Latinas who experience IPV “tend to be younger, have more socioeconomic disadvantage, and are fearful of seeking help from authorities” [ 20 ].

The marital status of female victims of IPV has been extensively studied, with common findings of IPV appearing to happen less often to married women in comparison to divorced or separated women in most countries [ 21 , 22 ]. However, the findings must be considered within cultural contexts. As previously stated, in some countries, married women are viewed as property of the husband, and physical aggression or violence towards the wife is tolerated or accepted within the culture. In general, cohabitating couples worldwide report higher rates of IPV. The higher rates could be related to socioeconomic status or to the perception that the relationship is less permanent. More studies need to address the contributing factors as to why cohabitating women tend to have a higher rate of IPV compared to married women, as well as examine the norms by varying cultures and their effect on IPV. Single women typically report less rates of IPV in comparison to married, divorced or separated women. However, this trend appears to vary by country. Single women in Canada and Australia, for example, report higher rates of IPV in comparison to married women in these two nations [ 22 ]. Possible contributing factors for the increase in IPV among single women in Canada and Australia could be related to age or to lifestyle choices. Riskier lifestyles could potentially expose younger women to a greater chance of experiencing intimate partner violence. Latin American and Caribbean nations, data indicate that IPV typically occurs more often among urban women in comparison to rural women [ 23 ]. Nonetheless, some studies in the United States suggest that IPV typically occurs more often in rural settings and small towns [ 24 , 25 ]. Further studies are needed to address the underlying causes of the link between sociodemographic factors and IPV.

3.3. Childhood Victimization

In addition to possible social factors influencing the rates of IPV, women impacted by childhood victimization can experience long term negative effects, and data suggest that “childhood victimization and domestic violence are highly correlated” [ 26 ]. For example, women who witnessed IPV during their childhood are more prone to experiencing IPV as adults [ 27 - 30 ]. Similarly, studies suggest that women who have been physically abused [ 31 - 34 ] or sexually abused [ 35 - 38 ] in childhood also are more likely to experience IPV in adulthood.

3.4. Mental Health

Research has shown that women who experienced IPV report increased levels of mental health symptomatology. For example, women who were abused by an intimate partner reported increased symptoms of depression, anxiety [ 39 , 40 ], and obsessive-compulsive characteristics [ 40 ]. Similarly, women exposed to IPV and who present depressive symptoms exhibit significant weight gain [ 41 ]. Low-income post-partum women in Brazil who experienced IPV are at a greater risk of presenting suicidal ideation [ 42 ], and women living in poverty in Nicaragua who were victims of IPV and perceived they did not receive social support from their families were more likely to indicate they had attempted suicide at some point in their lives [ 43 ]. There appears to be a bidirectional relationship between IPV and mental health problems. More specifically, at least one study has shown that women who experienced child abuse and subsequently developed mental health illnesses ( i.e. , Post Traumatic Stress Disorder, symptoms of depression, binge drinking) were more likely to experience IPV during adulthood [ 44 ].

3.5. Health Complains and Illnesses

In addition to mental health ailments, women victims of intimate partner violence (IPV), in its many forms, have self-reported having frequent health complaints and illnesses. Because of the complexity of physical ailments and symptoms, research studies are limited in addressing the specific correlations of physical health and IVP [ 45 ]. For example, Onur et al. (2020) wrote that women diagnosed with Fibromyalgia Syndrome (characterized by chronic musculoskeletal pain) also reported being victims of partner violence (physical, social, economic, and emotional) [ 46 ]. Raya et al. (2004) observed that Andalusian women victims of IPV perpetration were more likely to suffer from hypertension and asthma [ 47 ]. More recently, Soleimania et al. (2017) observed that Iranian women who had experienced IPV in the form of psychological abuse had a greater incidence of somatic symptoms than women who had not experienced any form of abuse [ 48 ]. There appears to be an additive effect on the body when it comes to experiencing abuse. Women who have experienced various forms of abuse in their life ( e.g. , child abuse, past IPV, present IPV, and financial problems) have reported higher levels of somatic complaints in comparison to women who had only experienced IPV [ 49 ]. At least one study noticed that there was a greater incidence of type 2 diabetes in women who reported experiencing physical intimate partner violence [ 50 ].

3.6. Utilization of Health Care Providers

Aside from the various somatic complaints that are being described by women who have experienced IVP, Lo Fo Wong, et al. (2007), observed that women who had been physically and psychologically abused by their partners used healthcare providers more often and were also prescribed pain medication more frequently [ 51 ]. Also, Comeau, et al. (2012) noticed that women who had been abused by their intimate partners used antidepressants to deal with symptoms of depression [ 52 ]. Lastly, higher use of anxiolytics and antidepressants also has been observed in women who had suffered intimate partner violence [ 53 ].

3.7. Use of Cigarettes

Aside from using various types of medications, Sullivan et al. (2015) noticed that women who had been victims of IPV tend to smoke greater quantities of cigarettes in comparison to women who have not experienced violence [ 54 ]. Furthermore, it has also been observed that women who experienced perinatal IPV were twice as likely to smoke cigarettes in comparison to women without a history of IPV [ 55 ]. It is worth noting that smoking during pregnancy is a strong predictor of low birth weight [ 55 - 57 ] and preterm birth [ 58 ]. Children born under these circumstances are more prone to being described as having more social problems, attention problems, as well as anxiety and depression by age 7 [ 59 ] and low birth weight adolescents show increased levels of mental health problems (emotional symptoms, social problems, and attention deficit) [ 60 ].

3.8. Current Scenario

Many contributing factors impact women suffering from intimate partner violence. These influences could be cultural, socioeconomic, political, and educational, to name a few. Major findings support the notion that women, who are less educated, socioeconomically disadvantaged, reside in patriarchal societies, or cohabitate are at greater risk of IPV. Another contributing factor is mental health symptomology. Further analysis is needed to better understand the correlation between mental health issues and IPV. Is poor mental health a precursor to IPV, or is IPV a potential cause for poor mental health? Various cultures have differing views pertaining to the topic of mental health and address this problem differently. Without proper treatment and proper advocacy for mental health, some women may feel caught in a cycle of hopelessness, stay in abusive relationships, and contribute to the social perception that IPV is an acceptable way of life.

With the current global crisis of COVID-19 and governments issuing stay-at-home orders, psychologists predict an increase in intimate partner violence. The Secretary-General of the United Nations stated the orders have led to a “horrifying global surge” in IPV [ 61 ]. Because of the difficulty to flee from the abusers, women may be at an even higher risk of “IPV-related health issues” [ 61 ]. The global pandemic is a major contributing factor to job loss, economic stress, and evictions. Economic crisis can potentially negatively impact relationships, regardless of marital status. With the looming effects of the pandemic, the World Health Organization will need to consider the level of depression, anxiety, stress, marital status, and socioeconomic status in women across varying cultures, and how the pandemic may have contributed to an increase in IPV.

3.9. Interventions

Empirically validated interventions aimed to address IPV are scarce. One study observed positive results through the implementation of a culturally relevant program with immigrants of Mexican origin. Specifically, the study observed that Latino men benefited from attending group sessions aimed to address, among others, their histories of childhood maltreatment, their challenges encountering different gender roles as they moved to the United States, their sense of control over their wives, and the development of “unequal but non-abusive relationships”. The program included teaching men non-aggressive strategies and problem-solving skills through role-plays. Through these interventions, men became more understanding of their wives’ experiences, as they transition to the United States, learned the impact of their aggressive behavior, and also learned to cooperate more within the home [ 62 ]. In addition to this report, another study focused on the empowerment of Latino women through the Moms’ Empowerment Program. This intervention included providing advocacy services and social support to women. It targeted women’s self-blame for experiencing IPV and helped women set forth goals to promote change in their lives while focusing on preserving their children’s safety. Overall, the program appeared to be successful in helping reduce women’s exposure to mild violence and physical assaults [ 63 ]. Another recent study carried out in Brazil observed positive results with the implementation of cognitive-behavioral interventions in women victims of IPV. Thirteen sessions with a weekly frequency, which included, among others, psychoeducation, problem-solving, and cognitive restructuring, showed effectiveness in reducing women's anxiety and depression and increasing their life satisfaction [ 64 ]. Aside from individual or group interventions, one study carried in Ghana examined the utilization of community-based structures ( i.e. , police, health and welfare organizations, and religious leaders) to raise awareness to the problem of violence against women, to guide talks about gender equality, challenge social norms that endorse violence, provide counseling services to couples experiencing IPV, and create referral structures to help victims.. The prevalence of IPV in the communities that received these types of interventions was lower than that of those areas that did not receive these services [ 65 ].

IVP is a complex issue that needs continued research and attention to provide better interventions. Global findings indicate that certain cultural groups are more tolerant of this problem and that they may tend to normalize it and/or accept it. Overall, IPV is more widespread in developing nations, especially those experiencing political-related-violence. Considering these findings, World Health Organization surveys and future studies should consider assessing the incidence of IPV among immigrants to the United States with histories of having experienced political violence. A study in 2008 showed that eleven percent of immigrant Latinos to the United States had experienced political violence in their countries of origin. Latino women who had lived this type of violence also reported experiences of feeling discriminated [ 66 ]. Future studies should focus their attention on clarifying these findings and their possible relationship with IPV, so that prompt interventions with immigrant populations could be developed.

A recent study shows that Hispanics and Blacks in the United States constantly worry about possibly experiencing violence perpetrated by police, a form of political violence. Hispanics worry about police violence four times more than Whites and Blacks worry about this type of violence five times more than Whites [ 67 ]. Considering these results, the WHO should also explore if reports of police brutality in black or immigrant communities in the United States correlate to rates of IPV in these communities.

Although there is ample information about the various factors associated with IPV, only a few studies have focused on examining empirically validated interventions to address it. Without this knowledge, it would be impossible to truly know if available interventions work or not. Research findings suggest that women, and in particular women from marginalized groups, should receive assistance and guidance to gain access to higher education institutions. Their educational attainment likely will become a protective factor in their life that could prevent them from ever experiencing IPV. Parity in access to higher-paying jobs likely could help reduce the prevalence of IPV. Well-implemented cultural change strategies also appear to be a solution to the problem of IPV. Societal structures ( e.g. , law, religion) and organizations ( e.g. , welfare) seem to be key participants in the development of respectful and nonviolent relationships between men and women that likely could prevent IPV from ever taking place. Early detection of violence within the home and follow-up interventions could prevent children from normalizing such behavior. Health care system screenings could detect early signs and symptomatology of IPV. These screenings could potentially ensure that multisystem interventions be implemented to disrupt the development of IPV and provide survivors with needed support. Lastly, research suggests that governments and their officials should refrain from endorsing politically violent acts. Governmental acts of violence likely could endorse or ignite the problem of IPV in nations.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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Published contents, about the editor, journal metrics, readership statistics:, total views/downloads: 2,732,932, unique views/downloads: 590,619, about the journal, table of contents.

• INTRODUCTION
• Searching Strategy
• Percentage of Women Experiencing Violence
• Social Norms and Sociodemographic Factors
• Childhood Victimization
• Mental Health
• Health Complains and Illnesses
• Utilization of Health Care Providers
• Use of Cigarettes
• Current Scenario
• Interventions

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A Social Learning Theory Model of Marital Violence

• Published: March 1997
• Volume 12 , pages 21–47, ( 1997 )

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• Sharon Wofford Mihalic 1 &
• Delbert Elliott 1  

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A social learning theory model of minor and severe marital violence offending and victimization among males and females was tested. Results support social learning as an important perspective in marital violence. However, males and females are impacted differently by their experiences with violence in childhood and adolescence. Prior experiences with violence have a more dramatic impact in the lives of females than males, both during adolescence and adulthood.

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Google Scholar  

Andrews, B., and Brown, G. W. (1988). Marital violence in the community. A biographical approach. Br. J. Psychiatry 153: 305–312.

Bandura, A. (1973). Aggression: A Social Learning Analysis , Prentice Hall, Englewood Cliffs, NJ.

Bandura, A. (1971). Psychological Modeling , Aldine-Atherton, Chicago, IL.

Bandura, A. (1969). Principles of Behavior Modification , Holt, Rinehart, and Winston, Inc., New York.

Browne, S. F. (1980). Analysis of a Battered Women Population , Denver Anti-Crime Council, 1445 Cleveland 1., Rm. 200, Denver, Colorado, 80202.

Burgess, A. W., Hartman, C. R., and McCormack, A. (1987). Abused to abuser: Antecedents of socially deviant behaviors. Am. J. Psychiatry 144(11): 1431–1436.

Coleman, D. H., and Straus, M. A. (1986). Marital power, conflict, and violence in a nationally representative sample of American couples. Viol. Vict. 1(2): 141–156.

Fagan, J. A., Stewart, D. K., and Hansen, K. V. (1983). Violent men or violent husbands? Background factors and situational correlates. In Finkelhor, D., Gelles, R. J., Hotaling, G. T., and Straus, M. A. (eds.), The Dark Side of Families , Sage, Beverly Hills, CA.

Finkelhor, D., Hotaling, G. T., and Yllo, K. (1988). Stopping Family Violence: Research Priorities for the Coming Decade , Sage, Newbury Park, CA.

Forsstrom, B., and Rosenbaum, A. (1985). The effects of parental marital violence on young adults: An exploratory investigation. J. Marr. Fam. 47(2): 467–480.

Gelles, R. (1972). The Violent Home: A Study of Physical Aggression Between Husbands and Wives , Sage, Newbury Park, CA.

Herrenkohl, E. C., Herrenkohl, R. C., and Toedter, L. J. (1983). Perspectives on the intergenerational transmission of abuse. In Finkelhor, D., Gelles, R. J., Hotaling, G. T., and Straus, M. A. (eds.), The Dark Side of Families , Sage, Beverly Hills, CA.

Hotaling, G. T., Straus, M. A., and Lincoln, A. J. (1990). Intrafamily violence and crime and violence outside the family. In Straus, M. A., and Gelles, R. J. (eds.), Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families , Transaction Publishers, New Brunswick, NJ.

Hotaling, G. T., Straus, M. A., and Lincoln, A. J. (1988). Violence and other crime outside the family. In Tonry, M., and Ohlin, L. (eds.), Crime and Justice. An Annual Review of Research , University of Chicago Press, Chicago, IL.

Hotaling, G. T., and Sugarman, D. (1986). An analysis of risk markers in husband to wife violence: The current state of knowledge. Viol. Vict. 1(2): 101–124.

Huizinga, D., and Elliott, D. (1986). Reassessing the reliability and validity of self-report delinquency measures. J. Quant. Criminol. 2: 293–327.

Kalmuss, D. (1984). The intergenerational transmission of marital aggression. J. Marr. Fam. February, 11–19.

Kaufman, J., and Zigler, E. (1987). Do abused children become abusive parents? Am. J. Orthopsychiatry 57(2): 186–192.

McCord, J. (1988). Parental behavior in the cycle of aggression. Psychiatry 51(1): 14–23.

Okun, L. (1986). Woman Abuse: Facts Replacing Myths , State University of New York Press, Albany, New York.

Rosenbaum, A., and O'Leary, K. D. (1981). Children: The unintended victims of marital violence. Am. J. Orthopsychiatry 51(4): 692–699.

Roy, M. (1982). Battered Women: A Psychosociological Study of Domestic Violence , Van Nostrand Reinhold Co., New York.

Seltzer, J. A., and Kalmuss, D. (1988). Socialization and stress explanations for spouse abuse. Social Forces 67(2): 473–491.

Steinmetz, S. K. (1977). The Cycle of Violence: Assertive, Aggressive, and Abusive Family Interaction , Praeger Publishers, New York.

Stith, S. M., and Farley, S. C. (1993). A predictive model of male spousal violence. J. Fam. Viol. 8(2): 183–201.

Straus, M. (1990a). Ordinary violence, child abuse, and wife beating: What do they have in common? In Straus, M. A., and Gelles, R. J. (eds.), Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families . Transaction Publishers, New Brunswick, NJ.

Straus, M. (1990b). The conflict tactics scales and its critics: An evaluation and new data on validity and reliability. In Straus, M. A., and Gelles, R. J. (eds.), Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families , Transaction Publishers, New Brunswick, NJ.

Straus, M., Gelles, R. J., and Steinmetz, S. K. (1980). Behind Closed Doors: Violence in the American Family , Anchor Press/Doubleday, Garden City, NY.

Walker, L. E. (1984). The Battered Woman Syndrome , Springer, New York.

Weis, J. G. (1989). Issues in the measurement of criminal careers. In Blumstein, A., Cohen, J., Roth, J. A., and Visher, C. A. (eds.), Criminal Careers and “Career Criminals,” Volume II , National Academy Press, Washington, DC.

Widom, C. W. (1989). The cycle of violence. Science 244(April): 160–244.

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Mihalic, S.W., Elliott, D. A Social Learning Theory Model of Marital Violence. Journal of Family Violence 12 , 21–47 (1997). https://doi.org/10.1023/A:1021941816102

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Study measures reflect self-reported responses by postpartum individuals 12 to 14 months after having a live birth. Detailed survey questions are included in eTable 1 in Supplement 1 . Percentages and 95% CIs were weighted to be representative of the 7 sample jurisdictions and to account for the Postpartum Assessment of Health Survey and Pregnancy Risk and Monitoring System nonresponse and sampling design. Error bars indicate 95% CIs.

Study measures reflect self-reported responses by postpartum individuals 12 to 14 months after having a live birth. Odds ratios (ORs) and 95% CIs were weighted to be representative of the 7 sample jurisdictions and to account for the Postpartum Assessment of Health Survey and Pregnancy Risk and Monitoring System nonresponse and sampling design. P values indicate the statistical significance of differences in the odds of reporting any item on the Mistreatment by Care Providers During Childbirth scale relative to the reference group based on unadjusted survey-weighted logistic regressions. Only characteristics with statistically significant comparisons are shown. IPFV indicates intimate partner or family violence; LGBTQ, lesbian, gay, bisexual, transgender, queer; PHE, public health emergency; and SUD, substance use disorder.

a Before or during pregnancy.

eTable 1. Mistreatment by Care Providers in Childbirth (MCPC) Survey Instrument

eTable 2. Sample Characteristics by Jurisdiction and Rates of Any Mistreatment

eTable 3. Unadjusted Associations Between Any Mistreatment and Patient Characteristics

eTable 4. Percentage of Respondents Experiencing Any Mistreatment by Race-Ethnicity, Marital Status, Sexual Orientation, and Insurance Status, for Combinations With Sample Size n ≥ 10

eTable 5. Individual Types of Mistreatment by Patient Characteristics

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Liu C , Underhill K , Aubey JJ , Samari G , Allen HL , Daw JR. Disparities in Mistreatment During Childbirth. JAMA Netw Open. 2024;7(4):e244873. doi:10.1001/jamanetworkopen.2024.4873

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Disparities in Mistreatment During Childbirth

• 1 Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York
• 2 Cornell Law School, Ithaca, New York
• 3 Department of Obstetrics and Gynecology, NewYork-Presbyterian/Columbia University Medical Center, New York, New York
• 4 Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles
• 5 Columbia University School of Social Work, New York, New York

Question   How often do birthing individuals in the US experience mistreatment by health care professionals during childbirth?

Findings   In this cross-sectional study, 13.4% of birthing individuals reported experiencing mistreatment during childbirth. Individuals at higher risk included those who were unmarried; were Medicaid insured; were lesbian, gay, bisexual, transgender, queer identifying; had obesity; had a history of substance use disorder, mood disorders, or intimate partner or family violence; or had an unplanned cesarean birth.

Meaning   These results suggest that structural social stigmas permeate the birth experience and shape how care is received, highlighting the need for patient-centered interventions to improve childbirth experiences.

Importance   Lack of respectful maternity care may be a key factor associated with disparities in maternal health. However, mistreatment during childbirth has not been widely documented in the US.

Objectives   To estimate the prevalence of mistreatment by health care professionals during childbirth among a representative multistate sample and to identify patient characteristics associated with mistreatment experiences.

Design, Setting, and Participants   This cross-sectional study used representative survey data collected from respondents to the 2020 Pregnancy Risk and Monitoring System in 6 states and New York City who had a live birth in 2020 and participated in the Postpartum Assessment of Health Survey at 12 to 14 months’ post partum. Data were collected from January 1, 2021, to March 31, 2022.

Exposures   Demographic, social, clinical, and birth characteristics that have been associated with patients’ health care experiences.

Main Outcomes and Measures   Any mistreatment during childbirth, as measured by the Mistreatment by Care Providers in Childbirth scale, a validated measure of self-reported experiences of 8 types of mistreatment. Survey-weighted rates of any mistreatment and each mistreatment indicator were estimated, and survey-weighted logistic regression models estimated odds ratios (ORs) and 95% CIs.

Results   The sample included 4458 postpartum individuals representative of 552 045 people who had live births in 2020 in 7 jurisdictions. The mean (SD) age was 29.9 (5.7) years, 2556 (54.4%) identified as White, and 2836 (58.8%) were commercially insured. More than 1 in 8 individuals (13.4% [95% CI, 11.8%-15.1%]) reported experiencing mistreatment during childbirth. The most common type of mistreatment was being “ignored, refused request for help, or failed to respond in a timely manner” (7.6%; 95% CI, 6.5%-8.9%). Factors associated with experiencing mistreatment included being lesbian, gay, bisexual, transgender, queer identifying (unadjusted OR [UOR], 2.3; 95% CI, 1.4-3.8), Medicaid insured (UOR, 1.4; 95% CI, 1.1-1.8), unmarried (UOR, 0.8; 95% CI, 0.6-1.0), or obese before pregnancy (UOR, 1.3; 95% CI, 1.0-1.7); having an unplanned cesarean birth (UOR, 1.6; 95% CI, 1.2-2.2), a history of substance use disorder (UOR, 2.6; 95% CI, 1.3-5.1), experienced intimate partner or family violence (UOR, 2.3; 95% CI, 1.3-4.2), mood disorder (UOR, 1.5; 95% CI, 1.1-2.2), or giving birth during the COVID-19 public health emergency (UOR, 1.5; 95% CI, 1.1-2.0). Associations of mistreatment with race and ethnicity, age, educational level, rural or urban geography, immigration status, and household income were ambiguous.

Conclusions and Relevance   This cross-sectional study of individuals who had a live birth in 2020 in 6 states and New York City found that mistreatment during childbirth was common. There is a need for patient-centered, multifaceted interventions to address structural health system factors associated with negative childbirth experiences.

Discrimination and lack of respectful care are thought to be key factors associated with disparities in maternal mortality and morbidity in the US. 1 , 2 Negative experiences during childbirth can have long-term consequences for birthing individuals, including posttraumatic stress disorder, negative body image, feelings of dehumanization, and changes in future reproductive decisions. 3 - 7 However, experiences of mistreatment during childbirth have not been widely documented in the US. In 2019, the Giving Voice to Mothers (GVtM) Study developed the Mistreatment by Care Providers in Childbirth (MCPC) scale, the first patient-designed and validated measure of self-reported mistreatment during childbirth in the US, to our knowledge. 7 Based on a convenience sample of birthing individuals from marginalized groups, the GVtM study found that 17% experienced mistreatment. Rates were higher among members of racial and ethnic minority populations and individuals with low socioeconomic status. 7 In 2023, the Centers for Disease Control and Prevention (CDC) measured mistreatment among a convenience sample of mothers with children younger than 18 years; 20% reported mistreatment during pregnancy and delivery, with higher rates among Black (30%), Hispanic (29%), and publicly insured mothers (26%). 8

Although these studies suggest that mistreatment during pregnancy and delivery is common in the US, both relied on convenience samples. The present study uses a large, representative, multistate sample to (1) estimate the prevalence of mistreatment by health care professionals during childbirth, (2) identify the most common types of mistreatment, and (3) identify the demographic, social, and clinical characteristics associated with mistreatment experiences.

For this cross-sectional study, we used data from the 2020 Postpartum Assessment of Health Survey (PAHS), a multistate survey of birthing individuals 12 to 14 months after a live birth in 6 states (Kansas, Michigan, New Jersey, Pennsylvania, Utah, and Virginia) and New York City. 9 The design of PAHS builds on the CDC Pregnancy Risk and Monitoring System (PRAMS). The participating jurisdictions were selected based on PRAMS sample size, meeting CDC PRAMS response rate thresholds, and their willingness and capacity to collaborate in the PAHS. 9 Each year, the PRAMS sampling frame comprises a stratified random sample of live births drawn monthly from state or city birth certificates. 10 Individuals in the 2020 PRAMS sampling frame gave birth between January and December 2020 and completed the PRAMS survey from 2 to 6 months post partum. PRAMS respondents were given the option to opt out of being contacted again for the PAHS from 12 to 14 months post partum. Verbal or written consent was obtained depending on the mode of the survey response. PAHS recruitment and data collection then occurred from January 1, 2021, to March 31, 2022. Of those contacted for the PAHS (6021 of 8473; 71.1% of 2020 PRAMS respondents), 4598 completed the survey (76.4% response rate). The PAHS was offered in English and Spanish. Individual-level PAHS responses were linked to PRAMS responses and birth certificate variables. This study was approved by the institutional review boards of the CDC, Columbia University, Rutgers University, and each local jurisdiction. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

The primary outcome was any mistreatment. The MCPC scale was developed and validated using a community-based participatory research process with targeted recruitment of pregnant individuals from racial and ethnic minority populations. 7 PAHS respondents were asked to think back to their birthing experience in the previous year to recall whether they had experienced any of 7 issues or behaviors from health care professionals during childbirth (eTable 1 in Supplement 1 ), which included physical abuse, verbal abuse (shouted at or scolded, or threatened), neglect, abandonment, lack of informed consent, and breach of confidentiality. Although not included in the MCPC scale, PAHS respondents could also indicate that they experienced any other mistreatment. Any mistreatment was coded as 1 if respondents answered yes to any of the 7 issues or any other mistreatment and 0 if respondents answered no to all.

We measured individual-level demographic, social, and clinical characteristics that have been associated with patients’ perinatal or other health care experiences in prior research. Self-reported race and ethnicity, which was shown to be a factor associated with mistreatment in the GVtM study, was measured on the PAHS. Respondents could choose between 8 categories: Asian; Black; Hispanic or Latinx; Native Hawaiian or Pacific Islander; Native American or Alaska Native; Southwest Asian, Middle Eastern, or North African; White; and multiple minoritized races. Most respondents (95.0% [4368 of 4596]) selected a single race and ethnicity category. We categorized individuals who selected 2 races and ethnicities, including White, as the other race and ethnicity, and those who selected multiple races and ethnicities other than White as “multiple minoritized races.”

Other sociodemographic characteristics included age; lesbian, gay, bisexual, transgender, queer (LGBTQ) identity; marital or domestic partner status; educational level; primary language; household income as a percentage of the 2021 federal poverty level; immigration status (for all jurisdictions except New York City); insurance coverage; and rural or nonrural geography (based on 2013 Rural-Urban Continuum Codes). 11 Missingness for sociodemographic variables measured in the PAHS was low (range, 0.1%-4.4%). For variables with an equivalent measure in the PRAMS or the birth certificate (race and ethnicity, age, marital status, educational level, income, and insurance at birth), we used these measures to impute the missing PAHS values.

We drew on prior studies of medical stigma and mistreatment to guide selection of other covariates. Intimate partner violence was associated with mistreatment in the GVtM study. 7 We therefore measured intimate partner or family violence (IPFV) during or 12 months before pregnancy by one’s husband, current or ex-partner, or another family member. Prior studies have shown that some physical and mental health conditions (eg, excess body weight and behavioral health disorders) carry stigmas that negatively shape health care professionals’ care and attitudes towards patients. 12 - 14 We measured obesity (body mass index ≥30 [calculated as weight in kilograms divided by height in meters squared]) prior to pregnancy and self-reported diagnosis of the following conditions before or during pregnancy: chronic medical conditions (asthma, diabetes, or hypertension), substance use disorder (SUD) or addiction (excluding smoking or tobacco use), and mood disorders (depression, anxiety, or another mood disorder).

Finally, we included birth characteristics that may shape an individual’s support, autonomy, and ability to participate in shared decision-making, 7 , 15 including parity; type of birth (vaginal, planned cesarean delivery, or unplanned cesarean delivery); a composite measure of higher-risk pregnancy (multiple births, preterm birth, gestational diabetes, or gestational hypertension); birth during the COVID-19 public health emergency (from March to December 2020); and presence or absence of a support person during childbirth (ie, no one, current partner or spouse, or others such as an ex-partner or ex-spouse or family members).

We estimated the survey-weighted rates of any mistreatment and each mistreatment indicator. We used survey-weighted logistic regression models to estimate odds ratios (ORs) and 95% CIs for the association between any mistreatment and patient characteristics. We aimed to identify the groups at highest risk of mistreatment; our goal was not to isolate the independent association of any one factor and mistreatment. We therefore did not adjust for covariates. Acknowledging that stigma and structural discrimination can result from multiple overlapping identities, 16 we further analyzed the intersectional associations of race and ethnicity with 3 demographic characteristics that had statistically significant associations with mistreatment: marital status, LGBTQ identity, and insurance coverage. To do so, we calculated survey-weighted rates of any mistreatment for groups defined by all 96 combinations of these 4 characteristics. We report rates only for the 29 groups with a total sample size of at least 10 individuals.

All estimates were weighted to be representative of live births in 2020 in the 7 jurisdictions. The PAHS weights accounted for the PRAMS stratified survey design, PRAMS nonresponse, and PAHS nonresponse. The PAHS weights were also calibrated to known population totals by maternal age, race and ethnicity, educational level, marital status, sampling strata, and infant birth weight based on 2020 live birth records in each jurisdiction. Missingness was low for the primary MCPC outcome (3.3%); thus, we conducted complete-case analysis. We conducted statistical tests using 2-sided tests and a significance level of P  < .05. Analyses were performed using Stata, version 17 (StataCorp).

Among the sample of 4458 postpartum respondents, representative of 552 045 people who had live births in 2020 in 7 jurisdictions, the mean (SD) age was 29.9 (5.7) years, 2556 (54.4%) identified as White, followed by Hispanic or Latinx (790 [18.3%]), Black (620 [15.0%]), or Asian (319 [8.9%]) ( Table 1 ). Overall, 2695 respondents (58.8%) were between 25 and 34 years of age when they gave birth, 4089 (91.1%) identified as non-LGBTQ, 3571 (78.0%) were married or in a domestic partnership, 3270 (68.5%) had higher than a high school education, and 3787 (82.6%) primarily spoke English. At the time of childbirth, 2836 participants (58.8%) were commercially insured, 1479 (37.9%) were insured by Medicaid, and 142 (3.2%) were uninsured.

Figure 1 shows rates of mistreatment overall and by type of mistreatment. A total of 13.4% (95% CI, 11.8%-15.1%) of birthing individuals in 2020 reported experiencing some form of mistreatment during childbirth. Being “ignored, refused request for help, or failed to respond in a timely manner” was the most commonly reported type of mistreatment (7.6%; 95% CI, 6.5%-8.9%), followed by being “shouted at or scolded” by health care clinicians (4.1%; 95% CI, 3.3%-5.2%), any other mistreatment (2.7%; 95% CI, 2.1%-3.4%), and having health care clinicians threaten “to withhold treatment or force you to accept treatment that you did not want” (2.3%; 95% CI, 1.7%-3.1%). Mistreatment rates ranged from 9.0% (95% CI, 7.0%-11.5%) in Kansas to 16.9% (95% CI, 13.9%-20.3%) in New York City (eTable 2 in Supplement 1 ).

Rates of mistreatment varied widely by race and ethnicity; however, we did not detect statistically significant differences between White respondents and other groups ( Table 2 ; eTable 3 in Supplement 1 ). Respondents who were Southwest Asian, Middle Eastern, or North African reported the highest rates of mistreatment (33.7%; 95% CI, 13.1%-63.2%), followed by individuals of multiple minoritized races (16.9%; 95% CI, 6.4%-37.9%), Black respondents (15.9%; 95% CI, 12.1%-20.6%), White respondents (13.3%; 95% CI, 11.0%-16.0%), Native American or Alaska Native respondents (12.5%; 95% CI, 3.3%-37.5%), Asian respondents (11.5%; 95% CI, 8.2%-15.9%), and Hispanic or Latinx respondents (10.8%; 95% CI, 8.4%-13.8%) ( Table 1 ).

Figure 2 shows the unadjusted ORs (UORs) for patient characteristics that were statistically significantly associated with any mistreatment. We found that LGBTQ respondents were twice as likely to experience any mistreatment compared with non-LGBTQ respondents (UOR, 2.3; 95% CI, 1.4-3.8). Odds of mistreatment were higher among those nsured by Medicaid at birth (UOR, 1.4; 95% CI, 1.1-1.8) and lower among respondents who were married relative to those who were not married or in a domestic partnership (UOR, 0.8; 95% CI, 0.6-1.0). Spanish language speakers were less likely to report mistreatment relative to primary English speakers (UOR, 0.5; 95% CI, 0.3-0.9). We did not identify statistically significant differences in mistreatment rates by age, educational level, rural or urban geography, immigration status, or household income (eTable 3 in Supplement 1 ).

Individuals with a history of SUD (UOR, 2.6; 95% CI, 1.3-5.1) and IPFV (UOR, 2.3; 95% CI, 1.3-4.2) were nearly twice as likely to report mistreatment relative to those without SUD or IPFV ( Figure 2 ). Respondents with mood disorders before or during pregnancy (UOR, 1.5; 95% CI, 1.1-2.2) and those who were obese prior to pregnancy (UOR, 1.3; 95% CI, 1.0-1.7) were also more likely to report mistreatment. Respondents with an unplanned cesarean birth (UOR, 1.6; 95% CI, 1.2-2.2) reported higher rates of mistreatment relative to those with a vaginal birth, as did those who gave birth during the COVID-19 public health emergency (UOR, 1.5; 95% CI, 1.1-2.0). We did not find statistically significant associations of mistreatment with support at childbirth, chronic physical conditions, parity, or higher-risk pregnancy (eTable 3 in Supplement 1 ).

The most common forms of mistreatment differed by patient characteristics (eTable 5 in Supplement 1 ). For example, LGBTQ individuals reported statistically significantly higher rates of being “threatened [with] withhold[ing] treatment or forced to accept [unwanted] treatment” compared with non-LGBTQ individuals (11.1% vs 1.9%). Southwest Asian, Middle Eastern, or North African respondents were more likely to report that their “physical privacy was violated, such as being uncovered or having people in the delivery room” without consent relative to White respondents (21.3% vs. 1.2%).

eTable 4 in Supplement 1 shows the rates of mistreatment by combinations of race and ethnicity, marital status, LGBTQ identity, and insurance at time of birth among sample sizes larger than 10. Across Black and White groups, the combination of identifying as LGBTQ, being unmarried, and Medicaid insured was associated with higher risk of mistreatment, with more than one-third of respondents with these intersecting identities reporting mistreatment (Black, 36.1%; 95% CI, 11.7%-70.5%; White, 36.2%; 95% CI, 9.7%-75.0%). Southwest Asian, Middle Eastern, or North African respondents who were Medicaid insured, married or in a domestic partnership, and non-LGBTQ identifying reported the highest rate of mistreatment (55.9%; 95% CI, 13.1%-91.4%); however, the 95% CIs were wide.

Using multistate representative survey data, we found that mistreatment by health care professionals during childbirth is a common experience in the US, affecting more than 1 in 8 individuals with a live birth in 2020. The highest rates of mistreatment occurred among individuals who were unmarried; Medicaid insured; LGBTQ identifying; obese; had a history of SUD, mood disorders, or IPFV; and those who had an unplanned cesarean birth.

The overall prevalence of mistreatment in our sample is lower than in the GVtM study (17.4% in a convenience sample drawn from marginalized communities 7 ) and the CDC survey (20% in an online convenience sample of mothers with children <18 years). 8 However, the prevalence rate in our study of 13.4%—representative of all birthing individuals in 6 states and New York City—suggests a need for interventions to improve respectful maternity care in the US. Similar to the CDC study, which did not conduct statistical testing, we found higher rates of mistreatment among Black and multiracial individuals, as well as those with public insurance. Similarities with the GVtM study include statistically significantly higher mistreatment rates among individuals with a history of SUD or IPFV, those with public insurance, and those with unplanned cesarean births. We also isolated risk factors not previously explored, including LGBTQ identity, obesity, mood disorders, and marital status.

Many of our results suggest that a pervasive structural social stigma permeates the birth experience and shapes how care is received. 17 For example, we found that LGBTQ-identifying individuals were twice as likely to experience mistreatment, associated with higher rates of feeling forced to accept unwanted treatment or being denied wanted treatment. These findings align with prior work demonstrating poorer birth outcomes among sexual minority women, 18 as well as research linking stigma and heterosexist policies to minority stress and adverse health outcomes among LGBTQ-identifying individuals. 19

Similarly, our results follow prior research that has linked stigma, discrimination in health care settings, and adverse health outcomes for people with excess body weight, 20 , 21 birthing individuals who are unmarried, 22 - 25 and individuals of low socioeconomic status who are publicly insured. 26 The high prevalence of mistreatment experienced by Medicaid-insured birthing individuals warrants attention, and Medicaid program administrators could explore options such as coverage for doulas and financial incentives to encourage respectful maternity care.

Our findings of increased mistreatment among patients with SUD, mood disorders, and a history of IPFV are concerning. Recent research has found that homicide, suicide, and drug overdose are leading causes of deaths after childbirth. 27 , 28 Mistreatment during childbirth may deter patients from seeking potentially lifesaving health care services, such as care for mental health, substance use, and experiences of IPFV. Mistreatment could also affect patients’ trust in health care professionals and affiliated institutions, with adverse long-term consequences for care seeking, disclosure to clinicians, and uptake of social services. Health care professionals and institutions could adopt targeted interventions to address the needs of at-risk patient groups, to foster inclusive and justice-informed care, and to actively discourage, make visible, and remedy discrimination against patients. 29 , 30

Unlike the GVtM study, we did not identify statistically significant associations of mistreatment with younger age (17-25 years), race and ethnicity, nulliparity, or having a high-risk pregnancy. The GVtM study found that Black, Hispanic, and Indigenous mothers were statistically significantly more likely than White mothers to experience mistreatment. In our study, Southwest Asian, Middle Eastern, or North African respondents were the most likely to report mistreatment, followed by Black individuals and people of multiple minoritized races. Group differences, however, were not statistically significant, which may be due to sample size and use of survey weighting, which reduces statistical power but allows for representative estimates.

Numerous studies have identified control—namely, participation in shared decision-making and patient-clinician communication, including managing complications—as one of the most important factors in birth satisfaction. 4 , 31 , 32 The high rate of mistreatment experienced by respondents with unplanned cesarean births may reflect the dynamics of patient disempowerment, such as loss of autonomy and lack of communication regarding the indication for the procedure. Reported mistreatment among those with unplanned cesarean births was largely driven by high rates of being forced to accept unwanted treatment or being threatened with withholding treatment.

This study also points to some conditions of care settings that might be associated with mistreatment experiences. Mistreatment was statistically significantly higher among respondents who gave birth in the months after the onset of the COVID-19 pandemic, when health care systems and personnel were experiencing extreme stress and resource scarcity. Health care professionals, staff members, facilities, and patients were all navigating a lack of vaccines, a shortage in personal protective equipment, and significant changes to hospital visitor policies that reduced and, in some cases, briefly eliminated support persons during labor and childbirth. Other studies have shown how the health, social, and policy contexts of the pandemic were adversely associated with maternity care and patient experiences. 33 - 35 The high proportions of respondents in our study who reported being “ignored,” being “refused requests for help,” and being “shouted at or scolded” may partly reflect clinician burnout and resource constraints.

This study has some limitations. First, while our findings were representative of the 7 included jurisdictions, which comprised 19.8% of US births in 2020, 36 the results may not be generalizable to all US jurisdictions. Second, some null results, including comparisons by race and ethnicity and immigration status (which was not collected in New York City), could be due to insufficient statistical power rather than lack of true differences. Third, “any other mistreatment” was the third most common form of mistreatment, suggesting that some perceived mistreatment experiences are not captured by the options in the MCPC scale. Incorporating the MCPC scale in larger population surveys, such as the PRAMS, with a free text option, would allow for the tracking of mistreatment rates across jurisdictions and over time, the exploration of other forms of mistreatment, and the statistical power to better evaluate disparities. Fourth, the MCPC scale does not capture mistreatment during pregnancy. Fifth, all variables are self-reported and could be subject to recall or social desirability bias (eg, reporting of SUD). Sixth, PAHS participants gave birth in 2020. Mistreatment rates could vary outside of the pandemic context. Seventh, while the PAHS was offered in Spanish, we found considerably lower rates of mistreatment among Spanish-speaking individuals. This finding could reflect a real difference or differences in the interpretation of the MCPC scale, which was not specifically validated for Spanish populations.

In this cross-sectional study conducted in 6 states and New York City, we found that mistreatment during childbirth was a common experience. To our knowledge, evidence of effective interventions to improve respectful maternity care in the US is scant. There is a need for the development and evaluation of patient-centered, multifaceted interventions that address implicit biases, cultural competence, health care workforce conditions, the inclusivity of clinical settings, and other structural factors, including health system factors, to improve childbirth experiences.

Accepted for Publication: February 6, 2024.

Published: April 4, 2024. doi:10.1001/jamanetworkopen.2024.4873

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Liu C et al. JAMA Network Open .

Corresponding Author: Chen Liu, MHS, Department of Health Policy and Management, Columbia University Mailman School of Public Health, 722 W 168th St, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Ms Liu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Liu, Underhill, Allen, Daw.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Liu, Allen.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Liu, Samari, Daw.

Obtained funding: Underhill, Allen, Daw.

Administrative, technical, or material support: Samari, Daw.

Supervision: Underhill, Aubey, Allen, Daw.

Conflict of Interest Disclosures: Dr Allen reported receiving grants from the National Institute on Minority Health and Health Disparities during the conduct of the study and serving as a commissioner on the Medicaid and CHIP Payment and Access Commission. Dr Daw reported receiving grants from the National Institutes of Health outside the submitted work. No other disclosures were reported.

Funding/Support: This study was funded by Columbia World Projects, Columbia University.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Any views or opinions expressed in this article are solely those of the authors, and no endorsement of these views or opinions by the authors’ institutions is expressed or implied.

Meeting Presentation: This study was presented at the Annual Research Meeting of AcademyHealth in 3 poster sessions over 2 days; June 25 and 26, 2023; Seattle, Washington.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: The Postpartum Assessment of Health Survey (PAHS) was a collaboration between Columbia University and the following state and city partners: Kansas Department of Health and Environment, Michigan Department of Health and Human Services, New Jersey Department of Health, New York City Department of Health and Mental Hygiene, Pennsylvania Department of Health, Utah Department of Health and Human Services, and Virginia Department of Health. The PAHS operations were conducted by the Kansas Department of Health and Environment (for Kansas) and the Rutgers Bloustein Center for Survey Research (for the other 6 sites). We acknowledge and thank the Centers for Disease Control and Prevention for coordinating with the PAHS team.

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A Review of Research on Women’s Use of Violence With Male Intimate Partners

Suzanne c. swan.

University of South Carolina

Laura J. Gambone

Jennifer e. caldwell, tami p. sullivan.

Yale University

David L. Snow

This article provides a review of research literature on women who use violence with intimate partners. The central purpose is to inform service providers in the military and civilian communities who work with domestically violent women. The major points of this review are as follows: (a) women’s violence usually occurs in the context of violence against them by their male partners; (b) in general, women and men perpetrate equivalent levels of physical and psychological aggression, but evidence suggests that men perpetrate sexual abuse, coercive control, and stalking more frequently than women and that women also are much more frequently injured during domestic violence incidents; (c) women and men are equally likely to initiate physical violence in relationships involving less serious “situational couple violence,” and in relationships in which serious and very violent “intimate terrorism” occurs, men are much more likely to be perpetrators and women victims; (d) women’s physical violence is more likely than men’s violence to be motivated by self-defense and fear, whereas men’s physical violence is more likely than women’s to be driven by control motives; (e) studies of couples in mutually violent relationships find more negative effects for women than for men; and (f ) because of the many differences in behaviors and motivations between women’s and men’s violence, interventions based on male models of partner violence are likely not effective for many women.

How you gonna love me, hurt me, and abuse me at the same time? You can’t love me and abuse me. 1

A sizable minority of individuals arrested for domestic violence each year in the United States is female ( Miller, 2005 ). For example, a study conducted in Tennessee found that 16% of those arrested for intimate partner violence were female ( Feder & Henning, 2005 ); in Concord, New Hampshire, women comprised 35% of those arrested ( Miller, 2005 ). Many of these women are court-mandated to receive services, such as a batterer intervention program or anger management program ( Miller, 2005 ). The military also provides services for a large number of women identified as committing physical abuse against a spouse. One study of 2,991 Air Force personnel who committed physical abuse against a spouse found that 23% of the offenders were female ( Brewster, Milner, Mollerstrom, Saha, & Harris, 2002 ). Another study of reports of spouse abuse in the Army Central Registry from 1989 to 1997 found that 33% of persons identified as domestic violence offenders were women ( McCarroll et al., 1999 ).

To aid those involved in the provision of services to women and their families involved in domestic violence, the following sections provide a review of key findings from research on women’s use of violence against male intimate partners. The review includes a discussion of the prevalence of women’s commission of different types of aggressive behaviors and how that compares to the prevalence of men’s commission of such behaviors; the prevalence of intimate partner violence among military personnel; ways in which women’s violence often differs from men’s violence; gender differences in the physical and psychological impact of domestic violence; gender differences in motivations for using violence; and characteristics of women who use violence against male intimate partners.

PREVALENCE OF WOMEN’S PERPETRATION OF DIFFERENT TYPES OF ABUSIVE BEHAVIORS

How prevalent is women’s intimate partner violence in the United States, and how does it compare to the prevalence of men’s intimate partner violence? The answer to this question varies depending on the type of aggression examined. The sections that follow describe gender similarities and differences that have been found in women’s and men’s physical aggression, sexual coercion, stalking, psychological aggression, and coercive control, as well as injury as a result of intimate partner violence.

Physical Aggression

When physical aggression is the subject of inquiry, studies consistently find that as many women self-report perpetrating this behavior as do men; some studies find a higher prevalence of physical aggression committed by women (for a review see Archer, 2000 ). For example, the National Family Violence Survey ( Straus & Gelles, 1990 ), a nationally representative study of 6,002 men and women, found that in the year before the survey, 12.4% of wives self-reported that they used violence against their husbands compared to 11.6% of husbands who self-reported using violence against their wives. Furthermore, 4.8% of wives reported using severe violence against their husbands, whereas 3.4% of husbands reported using severe violence ( Straus & Gelles, 1990 ). Studies with college samples also find that men and women commit similar rates of physical aggression ( Cercone, Beach, & Arias, 2005 ) or that a higher prevalence of women commit physical aggression ( Straus, 2004 ).

Sexual Coercion

Sexual coercion has been defined as “any situation in which one person uses verbal or physical means to obtain sexual activity against consent (including the administration of drugs or alcohol, with or without the other person’s consent)” ( Adams-Curtis & Forbes, 2004 , p. 91). Most studies comparing the prevalence of men’s and women’s sexually coercive behavior with intimate partners have been conducted with college student populations ( Katz, Carino, & Hilton, 2002 ; Ménard, Hall, Phung, Ghebrial, & Martin, 2003 ; O’Sullivan, Byers, & Finkelman, 1998 ; Straus, Hamby, Boney-McCoy, & Sugarman, 1996 ; Struckman-Johnson, Struckman-Johnson, & Anderson, 2003 ), with a few exceptions ( Feder & Henning, 2005 ; West & Rose, 2000 ). Regardless of the population investigated, every study found that a higher percentage of men commit sexually coercive behaviors against partners than do women ( Archer, 2000 ; Feder & Henning, 2005 ; Katz, Carino, et al., 2002 ; Ménard et al., 2003 ; O’Sullivan et al., 1998 ; Straus et al., 1996 ; Struckman-Johnson et al., 2003 ; West & Rose, 2000 ).

He want to know what I’m doing, where I’m going, what friend I’m with, what time I’m coming back . . . if he can’t get in touch with me, he’ll call a hundred times use different names, sit outside the house . . . wait to see what kind of car I’m coming in, and see if I’m coming with a guy or . . . you know, a woman.

The National Violence Against Women Survey, a nationally representative survey of 8,000 men and 8,000 women in the United States, assessed participants’ experiences of intimate partner violence and stalking. Stalking was defined by the survey as “a course of conduct directed at a specific person that involves repeated visual or physical proximity, nonconsensual communication, or verbal, written, or implied threats, or a combination thereof, that would cause a reasonable person fear” ( Tjaden & Thoennes, 1998 , p. 2). Stalking behaviors may include following or spying on someone, standing outside their home or workplace, making unwanted phone calls, or vandalizing their property ( Tjaden & Thoennes, 2000 ). The National Violence Against Women Survey found that the lifetime prevalence of having experienced stalking was 14.2% for women and 4.3% for men ( Davis, Coker, & Sanderson, 2002 ). Among those stalked, 41% of women and 28% of men were stalked by an intimate partner. Furthermore, women were 13 times as likely as men to report being very afraid of the stalker ( Davis et al., 2002 ), and the majority of both female and male stalking victims indicated that the perpetrators of the stalking were male ( Tjaden & Thoennes, 2000 ).

The National Violence Against Women study assessed experiences of stalking victimization, not stalking perpetration. In a study with 412 women who had committed physically violent behavior against a male partner ( Swan, Snow, Sullivan, Gambone, & Fields, 2005 ), women’s experiences of stalking victimization from their male intimate partners was assessed, as were women’s stalking behaviors toward their partners. All data were obtained from the women’s reports of their own and their partners’ behaviors. Consistent with the National Violence Against Women data, women were victims of stalking significantly more often than they perpetrated stalking behaviors.

Psychological Aggression

My experience wasn’t physical abuse, it was mental abuse and mine was feelings being hurt, and I feel like when my feelings are hurt, your feelings are going to be hurt, too.

Psychological aggression has been defined as “a communication, either verbal or non-verbal, intended to cause psychological pain to another person, or perceived as having that intent” ( Straus & Sweet, 1992 , p. 347) and as behavior that is demeaning, belittling, or that undermines the self-worth of one’s partner ( Tolman, 1989 ). Women used about as much psychological aggression as men in the National Family Violence Survey ( Straus & Sweet, 1992 ). Seventy-four percent of men and 75% of women in this survey reported that they committed at least one psychologically aggressive behavior against their partners in the past year ( Straus & Sweet, 1992 ). Men’s and women’s equivalent levels of psychological aggression have also been found in college samples. Cercone et al. (2005) found no significant differences between college men and women on the perpetration of minor (86% versus 89%, respectively) or more serious (30% versus 27%, respectively) forms of psychological aggression.

Coercive Control

[My friend] comes over . . . oh this man will get mad and go in the kitchen and just start slamming pots and pans and making a whole bunch of noise. And told me . . . “I don’t want nobody else in this house, cause if I do I’m gonna call the cops,” excuse me? Did you pay the rent this month? Oh no . . . I come from a family of 12 honey, I was controlled enough when I was growing up. No man, no, I am a stubborn person, no.

Coercive control is conceptualized as distinct from psychological aggression, and has been defined as “a pattern of coercion characterized by the use of threats, intimidation, isolation, and emotional abuse, as well as a pattern of control over sexuality and social life, including . . . relationships with family and friends; material resources (such as money, food, or transportation); and various facets of everyday life (such as coming and going, shopping, cleaning, and so forth)” ( Stark & Flitcraft, 1996 , pp. 166–167). The central features of coercive control include isolating the victim from her social network and the micromanagement of daily activities through the use of credible threats of negative consequences for noncompliance ( Dutton, Goodman, & Schmidt, 2006 ; Stark, 2006 ). From this perspective, physical and sexual violence are tools used by batterers to achieve coercive control of victims. Coercive control mirrors, in an exaggerated manner, cultural gender stereotypes that stipulate male dominance and female submissiveness. Stark (2006) also argues that it is coercive control, more than physical violence, that contributes to the devastating psychological effects of domestic violence on many of its victims, such as depression, anxiety, and posttraumatic stress disorder. One study found that, even after controlling for physical, sexual, and psychological abuse, coercive control was related to posttraumatic stress disorder ( Dutton et al., 2006 ).

Johnson (1995 , 2006) contends that coercive control is a critical factor that distinguishes different types of relationships in which intimate partner violence occurs. Relationships that are characterized by a pattern of coercive control and severe violence have been referred to as “intimate terrorism”; Johnson (2006) has found that the victims in these relationships are almost always female, and the perpetrators are almost always male. “Situational couple violence,” in contrast, is defined as “an intermittent response to the occasional conflicts of everyday life, motivated by a need to control in the specific situation but not a more general need to be in charge of the relationship” ( Johnson, 1995 , p. 286). In these relationships, violence usually does not escalate and is typically confined to a particular conflictual incident. It seems to be equally initiated by men and women ( Johnson, 2006 ; Stark & Flitcraft, 1996 ).

In one study of 412 women who had committed partner violence, women reported being victims of coercive control 1.5 times more often than they perpetrated these behaviors ( Swan et al., 2005 ). However, other authors propose that some forms of controlling behaviors are equally likely to be used by women and men ( Felson & Outlaw, 2007 ; Graham-Kevan, 2007 ). Clearly, more research is needed on this issue.

While survey studies find that women and men report the perpetration of physical aggression at similar rates, women are much more likely to be injured in domestic violence situations ( Archer, 2000 ; Feder & Henning, 2005 ; Hamberger, 2005 ; Temple, Weston, & Marshall, 2005 ; Whitaker, Haileyesus, Swahn, & Saltzman, 2007 ). For example, in the National Survey of Families and Households, of those who reported being injured by an intimate partner, 73% were female ( Zlotnick, Kohn, Peterson, & Pearlstein, 1998 ). In their study of men and women seeking emergency room care, Phelan et al. (2005) found that all of the women had received an injury from a partner, as compared to 39% of the men. Because men are usually larger and stronger than their female partners, men are more likely to injure their partners through relatively low-level violence, such as slapping or pushing ( Frieze, 2005 ). Women who have experienced violence from partners also are more likely than male victims to require medical attention for their injuries ( Hamberger, 2005 ; Tjaden & Thoennes, 2000 ), and one study found that the average cost per person of injuries caused by partner violence was twice as high for women as for men ( Arias & Corso, 2005 ).

How do prevalence rates of intimate partner violence compare across individuals in military and civilian settings? The next section addresses this question.

Prevalence Rates From Studies of Military Personnel

Studies of intimate partner violence conducted with military populations suggest that the prevalence of partner abuse may be somewhat higher than in civilian populations. Heyman and Neidig (1999) conducted a careful comparison of prevalence rates between a sample of 33,762 active-duty army personnel and the 6,002 participants in the National Family Violence Survey, correcting for demographic differences between the samples. They found no differences in male perpetration of moderate violence between the samples—10.8% of the male Army sample reported that they committed moderate spousal violence compared to 9.9% of the male civilian sample. However, rates of severe violence were significantly higher in the military sample: 2.5% of the male Army sample reported that they committed severe spousal violence compared to 0.7% of the male civilian sample. Regarding women’s perpetration of abusive behavior, the prevalence of moderate and severe spousal violence was significantly higher in the military sample—13.1% of women in the Army reported that they committed moderate violence compared to 10% of the civilian women, and 4.4% of women in the Army reported that they committed severe violence compared to 2% of civilian women.

In a large study of Navy recruits (1,307 men and 1,477 women), 32% of men and 47% of women reported using some form of physical aggression against an intimate partner in the past year ( White, Merrill, & Koss, 2001 ). The high prevalence rates among the Navy recruits are likely due in part to the young age of the sample; the average age of recruits was 20. The Navy prevalence rates are comparable to those of college populations and other young samples. For example, Straus’s (2004) international study of dating violence found that the percentage of college students who reported committing at least one act of physical aggression against a dating partner ranged from 12% to 42% for males and from 17% to 48% for females. Similarly, in a cohort study of 941 21-year-olds in New Zealand, physical aggression against an intimate partner was reported by 37% of women and 22% of men ( Magdol et al., 1997 ).

WHAT IS DIFFERENT ABOUT WOMEN’S VIOLENCE?

I’ve been beaten in my head with hammers, I had my ear drum busted, I had my nose busted, I been hit in the ribs with a bat, I’ve been thrown down cement stairs, I’ve got so many stitches in my face . . . when I started fighting back he know what happens now, [they] got these laws where you both fight you go to jail. So I got a jail record for assault—get this—I’m saying to myself God what is the justice in this.

Women’s Violence Usually Occurs in the Context of Violence Against Them by Their Male Partners

Studies have consistently found that the majority of domestically violent women also have experienced violence from their male partners. Two studies of ethnically diverse, low-income community women found a high prevalence of victimization among women who used violence. In Temple et al.’s (2005) study of Black, Mexican American, and White women, 86% of those who used violence were also victims; in Swan et al.’s (2005) study of Black, Latina, and White women, this figure was 92%. Similar results have been found with college women ( Cercone et al., 2005 ; Orcutt, Garcia, & Pickett, 2005 ). Among the women who reported using violence in the National Family Violence Survey, 64% also experienced violence from their male partners ( Straus & Gelles, 1990 ). Furthermore, several studies with women who have been arrested for domestic violence ( Hamberger & Guse, 2002 ; Stuart et al., 2006 ; Swan & Snow, 2002 ) found that the number of women reporting violence from their male partners was greater than 90%.

Thus, many domestically violent women—especially those who are involved with the criminal justice system—are not the sole perpetrators of violence. The victimization they have experienced from their male partners is an important contextual factor in understanding their motivations for violence. Some women who have been adjudicated for a domestic violence offense are, in fact, battered women who fought back ( Kernsmith, 2005 ; Miller, 2005 ). They may well be at the same level of risk of serious injury or death as battered women who are seeking shelter. Service providers working with domestically violent women may need to develop safety plans similar to those they would develop for battered women.

The Types of Violence Women Commit Differ From Men’s Violence

Women’s commission of different types of violence, and their experiences of violence from their male partners, were examined in two studies ( Swan & Snow, 2002 ; Swan et al., 2005 ). Participants in both studies were women who used violence against an intimate male partner. The studies found consistent results: Women and their partners used equivalent levels of psychological aggression. Women used higher levels of moderate physical violence than their partners used against them, and about the same level of severe physical violence. However, women were about 1.5 times more likely to experience coercive control as they were to be coercively controlling. Similarly, women were 2.5 times more likely to be sexually coerced than they were to use sexual coercion against their partners. And women were 1.5 times more likely to be injured than they were to injure their partners. Similar results were found in Stuart et al.’s (2006) study of 87 women participating in a court-mandated domestic violence intervention program. Swan et al. (2005) also found that women experienced stalking from their partners significantly more often than they committed stalking behaviors themselves.

While Swan et al. (2005) found that women reported using equivalent levels of severe violence compared to what their partners used against them, Temple et al. (2005) found that women’s violence was less severe than their partners’ violence against them, even in relationships in which the women were the primary aggressors. Taken together, these studies suggest that the types of violence women and men commit differ, even in relationships in which both partners use violence.

Domestic Violence May Affect Men and Women Differently

A mutually violent relationship, as defined in the intimate partner violence literature, is a relationship in which both partners use physical violence (e.g., Straus & Gelles, 1990 ). The extent to which one partner may be much more violent than the other, or to which one partner’s violence may be in self-defense, or to which one partner may be using more severe forms of violence than the other (e.g., sexual assault) is not taken into account in this definition.

The evidence presented above suggests that in many relationships that can be classified as mutually violent, women are more likely than men to experience severe and coercive forms of partner violence, such as sexual coercion and coercive control, and women are injured more often and more severely. It is not surprising, then, that relationships that are mutually violent have a more detrimental impact on women’s psychological and physical well-being, as compared to men ( Frieze, 2005 ; Hamberger, 2005 ). Utilizing information from the National Comorbidity Survey, Williams and Frieze (2005) found that female participants who experienced partner aggression reported significantly higher distress and lower marital satisfaction when compared to male participants who experienced partner aggression. Similarly, college women experienced lower relationship satisfaction as a function of partner violence, but men did not ( Katz, Kuffel, & Coblentz, 2002 ). And, in an examination of predictors of breakups in a national sample of couples, male violence, but not female violence, predicted relationship dissatisfaction and breaking up ( DeMaris, 2000 ).

Studies also find more negative psychiatric effects for women in mutually violent relationships when compared to men. Anderson (2002) examined 474 couples reporting mutual violence drawn from the National Survey of Families and Households and found that being in a mutually violent relationship predicted greater depression among both men and women, but the effect was approximately twice as great for women. A similar pattern was observed for drug and alcohol problems. In a longitudinal study, Ehrensaft, Moffitt, and Caspi (2006) found that women, compared to men, who were victims of intimate partner violence were more likely to develop psychiatric disorders. Studies with nationally representative samples have found that, compared to male victims of intimate partner violence, female victims are more likely to take time off from work ( Stets & Straus, 1990 ; Tjaden & Thoennes, 2000 ) and to make greater use of mental health and criminal justice system services ( Tjaden & Thoennes, 2000 ).

WOMEN’S MOTIVATIONS FOR VIOLENCE

He hit you one time, you give him that authority to hit you once, that’s it. He feel like he in control now, he can bust you upside the head anytime he want now. That’s why he hit you one time, you bust him right back . . . Bust him and run.

In addition to finding differences in the types of abusive behaviors men and women commit, as well as differences in outcomes of partner violence for men and women, studies also indicate that women’s motivations for using violent behavior in intimate relationships are often quite different from those of men.

Self-Defense

Women who engage in intimate partner violence commonly report using violence to defend themselves from their partners ( Babcock, Miller, & Siard, 2003 ), and several studies have found that women cite self-defense as a motivation for violence more frequently than men do (e.g., Barnett, Lee, & Thelen, 1997 ; Hamberger, 2005 ; Makepeace, 1986 ; but for an exception see Kernsmith, 2005 ). In an analysis of women’s motivations for violence ( Swan & Snow, 2003 ), self-defense was the most frequently endorsed motive, with 75% of participants stating that they had used violence to defend themselves. In Stuart et al.’s (2006) sample of women who were arrested for intimate partner violence, women’s violence was motivated by self-defense 39% of the time.

Like me, I’m the type that I’m violent with a man because before you getting me I’m getting you because I’m so scared now. My past relationship that I’ve seen with violence . . . I’m not gonna allow anyone to talk to me or hurt me any type of way.

Women are more likely to report fear in domestic violence situations ( Cercone et al., 2005 ; Foa, Cascardi, Zoellner, & Feeny, 2000 ; Hamberger, 2005 ; Jacobson et al., 1994 ; Kernsmith, 2005 ; Langhinrichsen-Rohling, Neidig, & Thorn, 1995 ; Morse, 1995 ; Phelan et al., 2005 ). Even among studies of male and female domestic violence defendants who were court-ordered to a domestic violence treatment program, women reported greater fear of their partner’s violence than did men ( Hamberger & Guse, 2002 ; Kernsmith, 2005 ).

Defense of Children

It has been estimated that 30% to 60% of children whose mothers are battered are themselves victims of abuse ( National Research Council, 1993 ; see also Edleson, 1999 ). Children living with an abused mother have been found to be 12 to 14 times more likely to be sexually abused than children whose mothers were not abused ( McCloskey, Figuerdo, & Koss, 1995 ). The effects of family violence on children, both in terms of actual physical abuse of children and the abuse that children witness, affect how women behave in violent relationships ( Dasgupta, 2002 ; Foa et al., 2000 ). Some women behave violently toward their partners to protect their children as well as themselves ( Browne, 1987 ; Morash, Bui, & Santiago, 2000 ).

Some . . . guys that’s controlling like that . . . you gotta watch out for that . . . because one of them times they could just snap and they could seriously hurt you. I been through that . . . it’s real dangerous to be with somebody that’s real controlling and real jealous.

A number of studies show that men are more likely than women to use violence to regain or maintain control of the relationship or a partner who is challenging their authority ( Barnett et al., 1997 ; Cazenave & Zahn, 1992 ; Ehrensaft, Langhinrichsen-Rohling, Heyman, O’Leary, & Lawrence, 1999 ; Jacobson, 1994 ; Makepeace, 1986 ; Renzetti, 1999 ). Findings from the Hamberger and Guse (2002) study of men and women court-ordered to a domestic violence treatment program indicated that men were more likely to initiate and control violent interactions, whereas women used violence but were not in control of the violent interactions with their partners. However, this does not mean that control motives are absent from women’s violence ( Hamberger, Lohr, Bonge, & Tolin, 1997 ). Swan and Snow (2003) found that 38% of women stated that they had threatened to use violence at least sometimes to make their partner do the things they wanted him to do; of those, 53% stated that the threats were effective at least some of the time. Similarly, Stuart et al.’s (2006) sample of women arrested for intimate partner violence indicated that the percentage of time they used violence “to get control over your partner” was 22%, “to get your partner to do something or stop doing something” was 22%, and “to make your partner agree with you” was 17% (p. 615).

Retribution

I got a very jealous violent streak . . . if I’m in love with [somebody] and they do something like . . . bring another girl around me or he tell me to pick up his cell phone knowing it’s a girl, I’m gonna react. I might just throw something at him, you know, I don’t know what I might do.

Several studies suggest that retribution for real or perceived wrongdoing is a common motivator of women’s violent behavior. Forty-five percent of the women in the Swan and Snow (2003) study stated that they had used violence to get even with their partners for something they had done. In Stuart et al.’s (2006) sample of women arrested for intimate partner violence, women indicated that 35% of the time they used violence to retaliate for being emotionally hurt by their partners, while 20% of the time the motive was to retaliate for being hit first. The reasons for men’s and women’s desires for retribution may differ, with women more frequently using violence in retaliation for being emotionally hurt ( Follingstad, Wright, Lloyd, & Sebastian, 1991 ; Hamberger et al., 1997 ). For example, among individuals in batterer intervention counseling, 42% of women (compared to 22% of men) stated they used violence to get back at a partner for hurting them emotionally ( Kernsmith, 2005 ). Women in this study also were more likely than men to state that they used physical aggression against their partners to retaliate for previous abuse and to punish them.

CHARACTERISTICS OF WOMEN WHO USE VIOLENCE

This next section examines risk factors and mental health– and substance abuse–related problems that are common among women who use violence.

Childhood Trauma

Evidence from several studies indicates that rates of childhood trauma and abuse are very high among women who use violence. Among Swan et al.’s (2005) sample of women who used intimate partner violence, 60% experienced emotional abuse and neglect, 58% were sexually abused, 52% were physically abused, and 41% were physically neglected (see also Swan & Snow, 2003 ). High rates of childhood abuse have also been found in studies of women in court-mandated treatment for domestic violence ( Dowd, Leisring, & Rosenbaum, 2005 ; Hamberger & Potente, 1994 ; Kernsmith, 2006 ; Leisring, Dowd, & Rosenbaum, 2003 ).

Experiences of childhood abuse have been found in several studies to be a risk factor for women’s violent and abusive behavior toward others ( Mihalic & Elliott, 1997 ; Straus, 1990 ; Sullivan, Meese, Swan, Mazure, & Snow, 2005 ; White & Humphrey, 1994 ). A longitudinal study of 136 women who were treated at a hospital for sexual abuse as children examined the impact of childhood abuse on the women’s adult relationships ( Siegel, 2000 ). The study found that childhood experiences of sexual abuse predicted both women’s use of violence against intimate partners and the partners’ use of violence against them. Experiences of being hit or beaten by a parent also predicted women’s violence against their partners.

Psychological Functioning

Four psychological conditions have been associated with traumatic experiences in general and domestic violence victimization in particular: depression, anxiety, substance abuse, and posttraumatic stress disorder ( Axelrod, Myers, Durvasula, Wyatt, & Chang, 1999 ; Foa et al., 2000 ). The prevalence of all of these conditions is very high among women who use intimate partner violence. For example, Swan et al.’s (2005) study of women who used violence against male partners found that 69% met criteria for depression on a screening measure. Almost one in three met criteria on a posttraumatic stress disorder screen. Nearly one in five were suffering from alcohol or drug problems, and 24% of the participants took psychiatric medication. Similarly, in their study of women participating in an anger management program for intimate partner violence, Dowd et al. (2005) found a high prevalence of depression (67%), bipolar disorder (18%), anxiety issues (9%), and substance use problems (67%). In addition, 30% reported suicide attempts, 20% had been hospitalized for psychiatric reasons, and 25% had been detoxified.

IMPLICATIONS FOR SERVICE PROVIDERS

The literature review and the data presented here provide important information for individuals providing services and interventions to women who are violent toward intimate partners. To a great extent, women who are violent are also victims of violence from their male partners. In addition, women are more likely than men to be injured during domestic violence incidents and to suffer more severe injuries. Thus, safety issues are paramount for women who are domestically violent.

In some cases, women may be perpetrating as much or more physical violence as their partners, but their partners may be committing other types of abuse that are not always assessed, such as sexual abuse or coercive control. We recommend that service providers assess not just physical violence but all types of abuse that the woman has perpetrated and that her partner may have perpetrated against her. Such an assessment may reveal, for example, that a woman’s physical violence is in response to her partner’s attempts to coercively control her. In this case, interventions to promote behavioral change in both partners would be necessary for the abuse to stop.

Because of the many differences in behaviors and motivations between men’s and women’s violence, as discussed here, interventions based on models of male violence against women may not be effective for many women ( Feder & Henning, 2005 ; Hamberger, 2005 ; Kernsmith, 2005 ). Gender-specific interventions tailored to the needs of women who are violent are more likely to be successful in creating behavior change.

Acknowledgments

The research described in this article was supported by the National Institute of Justice and the University of South Carolina Research Foundation.

1 Quotations throughout the paper are from participants of focus groups with women who used violence in their relationships with intimate male partners ( Swan, Snow, Sullivan, Gambone, & Fields, 2005 ).

Contributor Information

Suzanne C. Swan, University of South Carolina.

Laura J. Gambone, University of South Carolina.

Jennifer E. Caldwell, University of South Carolina.

Tami P. Sullivan, Yale University.

David L. Snow, Yale University.

• Adams-Curtis LE, Forbes GB. College women’s experiences of sexual coercion: A review of cultural, perpetrator, victim, and situational variables. Trauma, Violence, and Abuse. 2004; 5 :91–122. [ PubMed ] [ Google Scholar ]
• Anderson KL. Perpetrator or victim? Relationships between intimate partner violence and well-being. Journal of Marriage and Family. 2002; 64 :851–863. [ Google Scholar ]
• Archer J. Sex differences in aggression between heterosexual partners: A meta-analytic review. Psychological Bulletin. 2000; 126 :651–680. [ PubMed ] [ Google Scholar ]
• Arias L, Corso P. Average cost per person victimized by an intimate partner of the opposite gender: A comparison of men and women. Violence and Victims. 2005; 20 :379–391. [ PubMed ] [ Google Scholar ]
• Axelrod J, Myers HF, Durvasula RS, Wyatt GE, Chang M. The impact of relationship violence, HIV, and ethnicity on adjustment in women. Cultural Diversity and Ethnic Minority Psychology. 1999; 5 :263–275. [ Google Scholar ]
• Babcock JC, Miller SA, Siard C. Toward a typology of abusive women: Differences between partner-only and generally violent women in the use of violence. Psychology of Women Quarterly. 2003; 27 :153–161. [ Google Scholar ]
• Barnett OW, Lee CY, Thelen RE. Gender differences in attributions of self-defense and control in interpartner aggression. Violence Against Women. 1997; 3 :462–481. [ PubMed ] [ Google Scholar ]
• Brewster AL, Milner JS, Mollerstrom WW, Saha BT, Harris N. Evaluation of spouse abuse treatment: Description and evaluation of the Air Force family advocacy programs for spouse physical abuse. Military Medicine. 2002; 167 (6):464–469. [ PubMed ] [ Google Scholar ]
• Browne A. When battered women kill. New York: Free Press; 1987. [ Google Scholar ]
• Cazenave NA, Zahn MA. Women, murder, and male domination: Police reports of domestic homicide in Chicago and Philadelphia. In: Viano EC, editor. Intimate violence: Interdisciplinary perspectives. New York: Hemisphere; 1992. pp. 83–97. [ Google Scholar ]
• Cercone JL, Beach SRH, Arias I. Gender symmetry in dating intimate partner violence: Does similar behavior imply similar constructs? Violence and Victims. 2005; 20 (2):207–218. [ PubMed ] [ Google Scholar ]
• Dasgupta SD. A framework for understanding women’s use of nonlethal violence in intimate heterosexual relationships. Violence Against Women. 2002; 8 :1364–1389. [ Google Scholar ]
• Davis KE, Coker AL, Sanderson M. Physical and mental health effects of being stalked for men and women. Violence and Victims. 2002; 17 (4):429–443. [ PubMed ] [ Google Scholar ]
• DeMaris A. Till discord do us part: The role of physical and verbal conflict in union disruption. Journal of Marriage and the Family. 2000; 62 :683–692. [ Google Scholar ]
• Dowd LS, Leisring PA, Rosenbaum A. Partner aggressive women: Characteristics and treatment attrition. Violence and Victims. 2005; 20 (2):219–233. [ PubMed ] [ Google Scholar ]
• Dutton MA, Goodman L, Schmidt RJ. Development and validation of a coercive control measure for intimate partner violence: Final technical report. Washington, DC: U.S. Department of Justice; 2006. (USDOJ Document No. 214438) [ Google Scholar ]
• Edelson JL. The overlap between child maltreatment and woman battering. Violence Against Women. 1999; 5 (2):134–154. [ Google Scholar ]
• Ehrensaft MK, Langhinrichsen-Rohling J, Heyman RE, O’Leary KD, Lawrence E. Feeling controlled in marriage: A phenomenon specific to physically aggressive couples? Journal of Family Psychology. 1999; 13 :20–32. [ Google Scholar ]
• Ehrensaft MK, Moffitt TE, Caspi A. Is domestic violence followed by an increased risk of psychiatric disorders among women but not among men? A longitudinal cohort study. American Journal of Psychiatry. 2006; 163 :885–892. [ PubMed ] [ Google Scholar ]
• Feder L, Henning K. A comparison of male and female dually arrested domestic violence offenders. Violence and Victims. 2005; 20 (2):153–171. [ PubMed ] [ Google Scholar ]
• Felson RB, Outlaw MC. The control motive and marital violence. Violence and Victims. 2007; 22 :387–407. [ PubMed ] [ Google Scholar ]
• Foa EB, Cascardi M, Zoellner LA, Feeny NC. Psychological and environmental factors associated with partner violence. Trauma, Violence, & Abuse. 2000; 1 :67–91. [ Google Scholar ]
• Follingstad DR, Wright S, Lloyd S, Sebastian JA. Sex differences in motivations and effects in dating violence. Family Relations. 1991; 40 :51–57. [ Google Scholar ]
• Frieze IH. Hurting the one you love: Violence in relationships. Belmont, CA: Wadsworth; 2005. [ Google Scholar ]
• Graham-Kevan N. Johnson’s control-based domestic violence typology: Implications for research and treatment. Issues in Forensic Psychology. 2007; 6 :109–115. [ Google Scholar ]
• Hamberger LK. Men’s and women’s use of intimate partner violence in clinical samples: Toward a gender-sensitive analysis. Violence and Victims. 2005; 20 (2):131–151. [ PubMed ] [ Google Scholar ]
• Hamberger LK, Guse CE. Men’s and women’s use of intimate partner violence in clinical samples. Violence Against Women. 2002; 8 :1301–1331. [ Google Scholar ]
• Hamberger LK, Lohr JM, Bonge D, Tolin DF. An empirical classification of motivations for domestic violence. Violence Against Women. 1997; 3 :401–423. [ PubMed ] [ Google Scholar ]
• Hamberger LK, Potente T. Counseling heterosexual women arrested for domestic violence: Implications for theory and practice. Violence and Victims. 1994; 9 :125–137. [ PubMed ] [ Google Scholar ]
• Heyman RE, Neidig PH. A comparison of spousal aggression prevalence rates in the U.S. Army and civilian representative samples. Journal of Consulting and Clinical Psychology. 1999; 62 (2):239–242. [ PubMed ] [ Google Scholar ]
• Jacobson NS. Contextualism is dead: Long live contextualism. Family Process. 1994; 33 :97–100. [ Google Scholar ]
• Jacobson NS, Gottman JM, Waltz J, Rushe R, Babcock J, Holtzworth-Munroe A. Affect, verbal content, and psychophysiology in the arguments of couples with a violent husband. Journal of Consulting and Clinical Psychology. 1994; 62 :982–988. [ PubMed ] [ Google Scholar ]
• Johnson MP. Patriarchal terrorism and common couple violence: Two forms of violence against women. Journal of Marriage and the Family. 1995; 57 :283–294. [ Google Scholar ]
• Johnson MP. Conflict and control: Gender symmetry and asymmetry in domestic violence. Violence Against Women. 2006; 12 :1003–1018. [ PubMed ] [ Google Scholar ]
• Katz J, Carino A, Hilton A. Perceived verbal conflict behaviors associated with physical aggression and sexual coercion in dating relationships: A gender-sensitive analysis. Violence and Victims. 2002; 17 (1):93–109. [ PubMed ] [ Google Scholar ]
• Katz J, Kuffel S, Coblentz A. Are there gender differences in sustaining dating violence? An examination of frequency, severity, and relationship satisfaction. Journal of Family Violence. 2002; 17 :247–271. [ Google Scholar ]
• Kernsmith P. Exerting power or striking back: A gendered comparison of motivations for domestic violence perpetration. Violence and Victims. 2005; 20 (2):173–185. [ PubMed ] [ Google Scholar ]
• Kernsmith P. Gender differences in the impact of family of origin violence on perpetrators of domestic violence. Journal of Family Violence. 2006; 21 :163–171. [ Google Scholar ]
• Langhinrichsen-Rohling J, Neidig P, Thorn G. Violent marriages: Gender differences in levels of current violence and past abuse. Journal of Family Violence. 1995; 10 :159–176. [ Google Scholar ]
• Leisring PA, Dowd L, Rosenbaum A. Treatment of partner aggressive women. Journal of Aggression, Maltreatment, & Trauma. 2003; 7 :257–277. [ Google Scholar ]
• Magdol L, Moffitt TE, Caspi A, Newman DL, Fagan J, Silva PA. Gender differences in partner violence in a birth cohort of 21-year-olds: Bridging the gap between clinical and epidemiological approaches. Journal of Consulting and Clinical Psychology. 1997; 65 :68–78. [ PubMed ] [ Google Scholar ]
• Makepeace JM. Gender differences in courtship violence. Family Relations. 1986; 35 :383–388. [ Google Scholar ]
• McCarroll JE, Newby JH, Thayer LE, Norwood AE, Fullerton CS, Ursano RJ. Reports of spouse abuse in the U.S. Army Central Registry (1989–1997) Military Medicine. 1999; 164 :77–84. [ PubMed ] [ Google Scholar ]
• McCloskey LA, Figuerdo AJ, Koss MP. The effects of systemic family violence on children’s mental health. Child Development. 1995; 66 :1239–1261. [ PubMed ] [ Google Scholar ]
• Ménard KS, Hall GC, Phung AH, Ghebrial ME, Martin L. Gender differences in sexual harassment and coercion in college students: Developmental, individual, and situational determinants. Journal of Interpersonal Violence. 2003; 18 (10):1222–1239. [ PubMed ] [ Google Scholar ]
• Mihalic SW, Elliot D. A social learning theory model of marital violence. Journal of Family Violence. 1997; 12 :21–47. [ Google Scholar ]
• Miller SL. Victims as offenders: The paradox of women’s violence in relationships. New Brunswick, NJ: Rutgers University Press; 2005. [ Google Scholar ]
• Morash M, Bui HN, Santiago AM. Cultural-specific gender ideology and wife abuse in Mexican-descent families. International Review of Victimology. 2000; 7 :67–91. [ Google Scholar ]
• Morse BJ. Beyond the conflict tactics scale: Assessing gender differences in partner violence. Violence and Victims. 1995; 10 :251–272. [ PubMed ] [ Google Scholar ]
• National Research Council. Understanding child abuse and neglect. Washington, DC: National Academy Press; 1993. [ Google Scholar ]
• Orcutt HK, Garcia M, Pickett SM. Female-perpetrated intimate partner violence and romantic attachment style in a college student sample. Violence and Victims. 2005; 20 (3):287–302. [ PubMed ] [ Google Scholar ]
• O’Sullivan LF, Byers SE, Finkelman L. A comparison of male and female college students’ experiences of sexual coercion. Psychology of Women Quarterly. 1998; 22 :177–195. [ Google Scholar ]
• Phelan MB, Hamberger LK, Guse CE, Edwards S, Walczak S, Zosel A. Domestic violence among male and female patients seeking emergency medical services. Violence and Victims. 2005; 20 (2):187–206. [ PubMed ] [ Google Scholar ]
• Renzetti C. The challenge to feminism posed by women’s use of violence in intimate relationships. In: Lamb S, editor. New versions of victims: Feminists struggle with the concept. New York: New York University Press; 1999. pp. 42–56. [ Google Scholar ]
• Siegel JA. Aggressive behavior among women sexually abused as children. Violence and Victims. 2000; 15 :235–255. [ PubMed ] [ Google Scholar ]
• Stark E. Reply to Michael P. Johnson’s conflict and control: Gender symmetry and asymmetry in domestic violence. Violence Against Women. 2006; 12 :1019–1025. [ PubMed ] [ Google Scholar ]
• Stark E, Flitcraft A. Women at risk: Domestic violence and women’s health. Thousand Oaks, CA: Sage Press; 1996. [ Google Scholar ]
• Stets JE, Straus MA. Gender differences in reporting marital violence and its medical and psychological consequences. In: Straus MA, Gelles RJ, editors. Physical violence in American families: Risk factors and adaptations to violence in 8,145 families. New Brunswick, NJ: Transaction Publishers; 1990. pp. 151–164. [ Google Scholar ]
• Straus MA. Ordinary violence, child abuse, and wife beating: What do they have in common? In: Straus MA, Gelles RJ, editors. Physical violence in American families: Risk factors and adaptations to violence in 8,145 families. New Brunswick, NJ: Transaction Publishers; 1990. pp. 403–424. [ Google Scholar ]
• Straus MA. Prevalence of violence against dating partners by male and female university students worldwide. Violence Against Women. 2004; 10 :790–811. [ Google Scholar ]
• Straus MA, Gelles RJ. Physical violence in American families: Risk factors and adaptations to violence in 8,145 families. New Brunswick, NJ: Transaction Publishers; 1990. [ Google Scholar ]
• Straus MA, Hamby SL, Boney-McCoy S, Sugarman DB. The revised conflict tactics scale (CTS2) Journal of Family Issues. 1996; 17 :283–316. [ Google Scholar ]
• Straus MA, Sweet S. Verbal/symbolic aggression in couples; incidence rates and relationships to personal characteristics. Journal of Marriage and the Family. 1992; 54 (2):346–357. [ Google Scholar ]
• Struckman-Johnson C, Struckman-Johnson D, Anderson PB. Tactics of sexual coercion: When men and women won’t take no for an answer. The Journal of Sex Research. 2003; 40 (1):76–86. [ PubMed ] [ Google Scholar ]
• Stuart GL, Moore TM, Gordon KC, Hellmuth JC, Ramsey SE, Kahler CW. Reasons for intimate partner violence perpetration among arrested women. Violence Against Women. 2006; 12 (7):609–621. [ PubMed ] [ Google Scholar ]
• Sullivan TP, Meese KJ, Swan SC, Mazure CM, Snow DL. Precursors and correlates of women’s violence: Child abuse traumatization, women’s victimization, avoidance coping and psychological symptoms. Psychology of Women Quarterly. 2005; 29 :290–301. [ Google Scholar ]
• Swan SC, Snow DL. A typology of women’s use of violence in intimate relationships. Violence Against Women. 2002; 8 :286–319. [ PubMed ] [ Google Scholar ]
• Swan SC, Snow DL. Behavioral and psychological differences among abused women who use violence in intimate relationships. Violence Against Women. 2003; 9 :75–109. [ Google Scholar ]
• Swan SC, Snow DL, Sullivan TP, Gambone L, Fields A. Technical report for “An empirical examination of a theory of women’s use of violence in intimate relationships”. National Institute of Justice; 2005. Retrieved November 28, 2005, from http://www.ncjrs.gov/pdf-files1/nij/grants/208611.pdf . [ Google Scholar ]
• Temple JR, Weston R, Marshall LL. Physical and mental health outcomes of women in nonviolent, unilaterally violent, and mutually violent relationships. Violence and Victims. 2005; 20 :335–359. [ PubMed ] [ Google Scholar ]
• Tjaden P, Thoennes N. Stalking in America: Findings from the National Violence Against Women Survey. Washington, DC: U.S. Department of Justice, National Institute of Justice; 1998. NCJ 169592. [ Google Scholar ]
• Tjaden P, Thoennes N. Full report of the prevalence, incidence, and consequences of violence against women. Washington, DC: National Institute of Justice; 2000. [ Google Scholar ]
• Tolman RM. The development of a measure of psychological maltreatment of women by their male partners. Violence and Victims. 1989; 4 (3):159–177. [ PubMed ] [ Google Scholar ]
• West CM, Rose S. Dating aggression among low income African American youth: An examination of gender differences and antagonistic beliefs. Violence Against Women. 2000; 6 :470–495. [ Google Scholar ]
• Whitaker DJ, Haileyesus T, Swahn M, Saltzman LS. Differences in frequency of violence and reported injury between relationships with reciprocal and nonreciprocal intimate partner violence. American Journal of Public Health. 2007; 97 :941–947. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• White JW, Humphrey JA. Women’s aggression in heterosexual conflicts. Aggressive Behavior. 1994; 20 :195–202. [ Google Scholar ]
• White JW, Merrill LL, Koss MP. Predictors of premilitary courtship violence in a Navy recruit sample. Journal of Interpersonal Violence. 2001; 16 (9):910–927. [ Google Scholar ]
• Williams SL, Frieze IH. Patterns of violent relationships, psychological distress, and marital satisfaction in a national sample of men and women. Sex Roles. 2005; 52 (11/12):771–784. [ Google Scholar ]
• Zlotnick C, Kohn R, Peterson J, Pearlstein T. Partner physical victimization in a national sample of American families. Journal of Interpersonal Violence. 1998; 13 :156–166. [ Google Scholar ]

• Open access
• Published: 11 June 2022

Factors impacting antenatal care utilization: a systematic review of 37 fragile and conflict-affected situations

• Kameela Miriam Alibhai   ORCID: orcid.org/0000-0002-5552-3015 1 ,
• Bianca R. Ziegler 2 ,
• Louise Meddings 1 ,
• Evans Batung 3 , 4 &
• Isaac Luginaah 3 , 4  

Conflict and Health volume  16 , Article number:  33 ( 2022 ) Cite this article

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It is estimated that over 930 million people live in fragile and conflict-affected situations (FCAS) worldwide. These regions, characterized by violence, civil unrest, and war, are often governed by corrupt administrations who are unwilling to provide their citizens with basic human rights. Individuals living in FCAS face health inequities; however, women are disproportionally affected and face additional barriers to accessing sexual and reproductive services, including antenatal care (ANC). This systematic review aims to identify the factors that impact ANC usage in the 37 countries or regions classified as FCAS in 2020 by The World Bank.

Using the PRISMA guidelines, a systematic search of five databases (SCOPUS, Web of Science, PubMed, EMBASE, and CINAHL) was conducted. Results were limited to human studies, written in English, and published between January 2002 and January 2022. Studies that identified factors affecting utilization of ANC or maternal health services were included for review and critically appraised using the National Institute of Health’s Quality Assessment Tools. Findings were summarized using a narrative synthesis approach.

The database search yielded 26,527 studies. After title, abstract and full-text review, and exclusion of duplicate articles, 121 studies remained. Twenty-eight of the 37 FCAS were represented in the included studies. The studies highlighted that women in FCAS’ are still not meeting the World Health Organization’s 2002 recommendation of four ANC visits during pregnancy, a recommendation which has since been increased to eight visits. The most cited factors impacting ANC were socioeconomic status, education, and poor quality of ANC. Despite all studies being conducted in conflict-affected regions, only nine studies explicitly identified conflict as a direct barrier to accessing ANC.

This review demonstrated that there is a paucity in the literature examining the direct and indirect impacts of conflict on ANC utilization. Specifically, research should be conducted in the nine FCAS that are not currently represented in the literature. To mitigate the barriers that prevent utilization of maternal health services identified in this review, policy makers, women utilizing ANC, and global organizations should attempt to collaborate to enact policy change at the local level.

Introduction

As of 2022, it is estimated that over 930 million people live in fragile and conflict-affected situations (FCAS) worldwide and the number of individuals affected by conflict continues to rise [ 1 ]. FCAS are countries or regions characterized by a high propensity for recurring conflict or war. FCAS often have unstable and corrupt governments who are unwilling to provide basic resources and protect the human rights of their citizens [ 2 , 3 , 4 ]. In 2020, the World Bank classified 37 countries as fragile and conflict-affected in their annual list of FCAS.

Conflict presents as one of the world’s most significant threats to health [ 5 ]. Individuals living in FCAS suffer worse health on numerous outcomes including trauma and injuries, infectious and chronic disease, mental health, child health, and malnutrition [ 6 ]. Women, in particular, are heavily affected by ongoing conflict and violence as they obtain lower levels of education, do not have the autonomy to make decisions regarding their health, and experience abhorrent gender-based violence [ 7 , 8 ]. In FCAS, women face increased barriers to accessing a continuum of sexual, productive, and maternal health services, including antenatal care (ANC). This has negative impacts on maternal mortality rates (MMR) worldwide [ 6 ]. The United Nations created Sustainable Development Goal (SDG) 3.1 in 2015 to reduce the global MMR to less than 70 per 100,000 live births by 2030 [ 9 ], from an estimated rate of 211 per 100,000 live births in 2017 [ 10 ]. Although the MMR goal outlined in SDG 3.1 is considerably lower than the current global MMR, this difference is even greater when compared to the MMR of FCAS—583 per 100,000 live births as of 2017 [ 11 ]. To work towards achieving SDG 3.1, increased attention and interventions are needed to improve maternal health service utilization in FCAS, where the MMR are highest.

ANC has been cited by numerous studies as a type of maternal health service that, if utilized, has the potential to reduce maternal mortality [ 12 , 13 , 14 ]. ANC is care provided to pregnant women by healthcare practitioners to identify maternal risks, prevent and manage complications, encourage positive health behaviours, and build a therapeutic patient–provider relationship [ 15 ]. In 2002, the World Health Organization (WHO) created the first set of ANC recommendations, which consisted of one first trimester visit and three subsequent visits [ 13 ]. In 2016, the WHO’s ANC recommendations increased from four total visits to eight [ 16 ]. Studies conducted prior this new recommendation in FCAS have found that the majority of women in these regions are not meeting the ANC recommendations established in 2002 [ 17 ].

This systematic review is grounded in Andersen’s Model of Healthcare Utilization [ 18 ] (Fig.  1 ). This theoretical framework conceptualizes healthcare utilization as a function of the interaction between predisposing, enabling, and need factors that influence whether women are able to seek ANC as recommended. This model was used to create themes which were found to impact women’s ANC usage and to analyze the data extracted from included articles.

Andersen’s model of healthcare utilization (Andersen, 1995)

FCAS have been previously studied, as have the numerous health outcomes of individuals living in FCAS, including maternal health. However, the common factors that prevent women living in FCAS from accessing ANC have not been well studied. Furthermore, there is a paucity in the literature on the impact of conflict on health equity in FCAS, including the intersectional effect of gender within these situations [ 2 ]. This systematic review aims to better understand the access to maternal health services in FCAS and the factors that contribute to the inequitable gap in ANC utilization. For the purposes of this study, ANC will be defined as a visit to a healthcare practitioner to receive services, such as laboratory tests, scans, or advice regarding health behaviours, while pregnant. Visits at the time of childbirth will be excluded. Our specific objectives are to (1) identify the predisposing, enabling, and need factors which prevent and/or enable women living in FCAS from utilizing ANC according to Andersen’s Model of Healthcare Utilization [ 18 ]; and (2) identify the effects of persistent conflict on women’s access to and utilization of ANC in the 37 FCAS globally.

This systematic review was carried out to examine the barriers, facilitators, and overall factors that impact ANC usage in the 37 countries or regions classified as FCAS in 2020 by The World Bank (Fig.  2 ). A systematic review protocol was developed using the PRISMA checklist and uploaded to the International prospective register of systematic reviews (PROSPERO) on July 10th, 2020 (ID #: CRD42020180994).

The World Bank’s 2020 list of fragile and conflict-affected situations

Search strategy

A literature search of peer-reviewed articles was conducted using SCOPUS, Web of Science, PubMed, EMBASE, and CINAHL. All five databases were searched on January 11, 2022 using a combination of MeSH terms and keywords (Table 1 ). The search strategy was created with the help of a subject-specific librarian and adapted to each database. Search results were limited to human studies, written in English, and published between January 2002 and January 2022.

All relevant studies were imported into Covidence, a web-based systematic review software, which identifies and removes duplicates, streamlines screening of citations, and facilitates the resolution of conflicts between reviewers. Two reviewers (B.Z. and K.A.) individually screened all titles, abstracts, and full texts. Disputes were resolved through general discussion with the senior author (I.L) when necessary.

Study inclusion and exclusion criteria

Studies were eligible for inclusion if they were conducted in a conflict-affected region of one of the 37 FCAS. To achieve this, the authors identified medium and high conflict zones within each FCAS, using the Humanitarian Data Exchange or the Armed Conflict Location and Event Data Project. Any studies that took place (1) in a low conflict area of an FCAS without widespread conflict or (2) in an unspecified region of an FCAS, were excluded. Studies that utilized nationwide data, such as the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Studies (MICS), and took place in FCAS where conflict was not widespread, were excluded. This was done to ensure the data analyzed was focused on conflict-affected populations within FCAS. However, studies that utilized nationwide data were included if the FCAS had widespread conflict, such as Afghanistan. Studies published between January 2002 and January 2022 were eligible for inclusion. The year 2002 was chosen as this was when the WHO released their first set of recommendations for focused and goal-oriented ANC in an attempt to extend antenatal coverage in low- and middle-income countries [ 15 ]. Studies that identified barriers or facilitators of ANC use were included in the review. Data from women who were pregnant and had received a minimum of one ANC visit were also included in the review. Regarding study design, both quantitative and qualitative studies were eligible for inclusion. Poster presentations, conference abstracts, theses, and studies for which the full text could not be located were excluded from the review. Studies that only examined skilled birth were excluded as this type of care has been more widely studied in the context of FCAS and is not an outcome of interest in this review.

Data extraction

Two reviewers (B.Z and K.A.) independently extracted data from all included studies. Data extracted included: list of authors, year of publication, study design, methodology employed, geographic setting, patient demographics (i.e., age, marital status), type of care provided (i.e., ANC, skilled birth), factors affecting ANC (i.e., distance, education), outcomes of interest (i.e., number of ANC visits), overall conclusions, limitations, and future recommendations. Data was extracted into a standardized extraction form developed by one of the study authors (B.Z.) using Qualtrics, an online survey platform. All bibliographic information was imported into a reference manager, Zotero, to generate citations.

Quality assessment

Each source was critically appraised using the National Institutes of Health (NIH) Study Quality Assessment Tools [ 19 ]. The NIH tool utilized was specific to the study design of the article being reviewed. Studies were evaluated on the clarity of the research question, described eligibility criteria, choice of study population, sample size, outcomes measured, and type of statistical analysis employed. After the assessment, articles rated as either “good”, or “fair” were deemed to have high internal validity and were included in the review. Eight studies were classified as “poor” quality which would have caused them to be excluded, however, they were also excluded for other reasons including wrong geographic location. Discrepancies between reviewers were resolved through general discussion with the senior author (I.L.) when necessary.

Data synthesis

A narrative synthesis approach was employed to analyze the data extracted from all included articles. The factors that were found to affect ANC utilization across all included studies were inductively coded [ 20 ] by two independent authors (B.Z and K.A) according to Andersen’s Model of healthcare utilization. Factors were coded as either predisposing , enabling , need or other factor type. To gain cross-study synthesis, the geographic distribution of the studies, participant demographics, and primary outcomes measured were analyzed and the percentage of women who met the ANC recommendations were calculated whenever possible. Due to the inclusion of qualitative studies and of studies with varied designs and methodologies, the data collected was heterogenous and a meta-analysis could not be carried out.

The database search yielded 26,527 studies. After exclusion of 11,029 duplicate articles, and completion of title and abstract screening, a total of 739 studies were included for full text review. After applying inclusion and exclusion criteria, 121 studies were retained for inclusion in the final dataset (Fig.  3 ). Due to the large number of full-text studies included in this review and the heterogeneity in the designs of the included studies, a thematic description of the results is presented. A description of each article is outlined in the Additional file 1 : Table S1.

PRISMA diagram. *The total number of reasons for exclusion of the full texts exceeds 618 as some studies were excluded for multiple reasons (i.e., poor quality in addition to another factor)

The geographical spread of the studies included in this systematic review and the number of articles per country is outlined in Fig.  4 . The number of articles represented within Fig.  4 exceeds the total number of studies included as some articles examined ANC in multiple countries. Among the 121 articles included, ANC usage was examined in 123 settings: 77 articles in Africa, 15 articles in the Middle East, six articles in Southeast Asia, 11 articles in Central Asia, nine articles in Oceania, three articles in the Caribbean, one article in Palestine, and one article in Europe. Specifically, ANC was examined in 28 of the 37 regions identified as FCAS in 2020 by The World Bank. The nine FCAS for which no relevant studies were found include: Congo (Rep), Liberia, Central African Republic, Comoros, Venezuela, Kiribati, Marshall Islands, Federated States of Micronesia, and Tuvalu. Thirty-two studies analyzed utilization of care in Nigeria, which highlights that ANC has been extensively studied in this country.

Geographic spread of articles (n = 99)

The studies included were published between 2002 and 2022, with most articles being published in 2014 or later (Fig.  5 ). The increasing number of studies over time indicates that research on ANC has been of interest since the Millennium Development Goals and SDGs targets on maternal mortality were established in 2000 and 2015, respectively.

Publication year of included articles (n = 121)

Overall, the studies suggest that booking the first ANC visit late in pregnancy is very common in FCAS [ 21 , 22 , 23 , 24 , 25 ]. Many studies also indicate that while progress has been made, women in FCAS are not meeting the WHO 2002 recommendation of four ANC visits and are therefore not meeting the 2016 recommendation of eight ANC visits [ 26 , 27 ]. Table 2 identifies the factors that impact use of ANC in the 121 included articles. Seeing that many studies identified multiple factors that impact ANC utilization, the total number of factors highlighted in Table 2 exceeds 121. In accordance with Andersen’s model, predisposing factors include demographic, social, and contextual items such as education, employment, marital status, gender dynamics, religion, and culture [ 28 , 29 ]. Enabling factors include financial and organizational items such as conflict, structural resources, safety, distance from ANC resources, perceived poor quality of ANC, and socioeconomic status [ 28 , 29 ]. Additionally, need factors, which indicate a woman’s perceived need for ANC, include parity and previous complications. Finally, factors such as unwanted pregnancies, interventions (i.e., performance-based financing, home visits, mobile phone support and health education), and a husband’s education or employment were categorized as  other . The most cited factors impacting ANC were socioeconomic status, poor quality of ANC, and education. Table 2 presents the 20 factors impacting ANC identified in the 121 included articles.

Predisposing

Demographic characteristics.

Demographic factors, including level of education, region of residence, marital status, age, religion, and ethnicity were cited 115 times as factors that impact ANC utilization. Education was the second most commonly cited factor that influenced ANC use in 49 studies (Table 2 ). Generally, women with no education or lower levels of education had decreased awareness and utilization of ANC during the first trimester and were less likely to receive the recommended number of ANC visits [ 30 ]. In contrast, women with higher levels of education were significantly more likely to book ANC early in pregnancy and to attend the recommended number of ANC visits [ 31 ]. Numerous studies also demonstrated that a husband’s level of education impacted a woman’s ANC usage [ 30 ]. It should be noted that this effect was smaller than the impact of a women’s educational attainment.

Region of residence and rurality were found to impact women’s utilization of ANC in 15 articles. The majority of studies found that, when compared to women living in rural areas, women living in urban areas within an FCAS were more likely to receive the recommended number of ANC visits and to have increased uptake of ANC overall [ 32 ].

Marital status was reported as a factor that influenced ANC utilization in 14 studies. In general, married women were more likely to use ANC as recommended compared to single women [ 33 , 34 ]. Specifically, the studies found that being married increased the likelihood of early initiation of ANC [ 33 ]. The type of marital union also impacted ANC usage, where women in polygamous marriages were more likely to utilize ANC services [ 34 ].

Maternal age was shown to be a factor influencing the timing and frequency of ANC utilization in 14 studies. Most studies, with the exception of Benage et al. [ 27 ] and Bashour et al. [ 35 ], found that younger women were less likely to seek ANC early in pregnancy, receive the four recommended ANC visits, and use ANC overall [ 36 ].

Religion was reported to be a factor influencing ANC utilization in nine studies, however, its impact was context dependent. De Allegri et al. [ 34 ], found a negative association between traditional African religions and ANC uptake. Conversely, a study by Nwakamma et al. [ 37 ], found that introducing and connecting women to ANC services through faith-based communities and leaders was an important factor in promoting ANC.

Finally, an individual’s employment status was reported to be both a facilitator and barrier to ANC uptake in eight studies. Failing et al. [ 38 ], found that women’s employment negatively impacted use of ANC, where women placed more importance on completing work responsibilities to survive financially than on take time off to receiving ANC. According to other studies, using ANC four times, as previously recommended by the WHO, was generally positively associated with women’s employment [ 17 , 39 , 40 ]. Additionally, numerous studies found that a husband’s occupation or employment status (categorized as other ) positively influenced women’s maternal healthcare utilization. To illustrate, Abimbola 2016 [ 30 ], found that a man’s occupation determines their wife’s socioeconomic status, which is an enabling factor that impacts ANC utilization [ 26 , 38 , 41 ].

Gender dynamics

Gender dynamics, which for the purposes of this study includes autonomy, decision-making abilities, and intimate partner violence, was found to impact ANC use in 26 studies. Women with higher autonomy, specifically financial autonomy, and increased decision-making abilities had greater uptake of ANC [ 42 , 43 ]. Receiving permission from the husband was cited as an additional barrier to accessing ANC in numerous studies [ 44 , 45 , 46 ]. Furthermore, women who did not experience intimate partner violence and who did not believe that wife-beating was acceptable were more likely to use ANC and meet the recommendation of four ANC visits [ 17 ].

Cultural and health beliefs

Cultural and health beliefs were reported to influence ANC uptake in 22 and 6 studies, respectively (Table 2 ). Culture was found to shape a woman’s beliefs about ANC and pregnancy, as well as her autonomy to make healthcare decisions [ 22 ]. For example, some women believed that their baby would be in danger or that enemies would bewitch them and cause them to miscarry if the pregnancy was disclosed too early, which resulted in late initiation of ANC [ 22 , 47 ]. Furthermore, in some traditions it is customary for a woman’s mother-in-law to decide whether or not she can receive care [ 46 , 48 ], which can further decrease ANC utilization. Women’s health beliefs, specifically those who believed that ANC was beneficial, were more likely to use maternal health services compared to those who believed ANC was only for curative purposes. Additionally, many women believed that pregnancy is a natural process and care should only be sought if one becomes ill or develops complications [ 49 , 50 ]. Therefore, the type of health belief that a woman held regarding the utility of ANC played a role in whether or not they utilized it.

Socioeconomic status

Socioeconomic status or financial difficulty was the most cited factor that prevented women from using ANC early and receiving the recommended number of visits. It was reported to influence ANC uptake in 68 of the 121 studies included in this review. The majority of studies found that women with higher socioeconomic status or wealth were more likely to utilize ANC in general, to initiate ANC early in pregnancy, and to receive the four recommended visits [ 26 , 38 , 41 ].

Distance & transport

Distance to the nearest ANC facility was the fourth most commonly cited reason for late or insufficient ANC uptake in 47 studies (Table 2 ). Women who lived closer to healthcare facilities or perceived the nearest healthcare facility as close to them, had higher levels of ANC usage. Unsurprisingly, those who lived further away from the nearest health facility were less likely to receive four ANC visits, initiate ANC early in their pregnancy, and use ANC overall [ 51 , 52 ]. Transportation was found to be a barrier of ANC uptake in 14 studies included (Table 2 ). Telfer et al. found unavailability of transportation to be one of the most important barriers preventing women from accessing ANC. Pregnant women also cited having to walk to the ANC facility and having inadequate modes of transportation (i.e., rickshaws, bicycles, motorbikes) as key barriers to accessing care. The high cost of transportation was also associated with fewer ANC visits and an overall lack of ANC utilization [ 30 , 64 ].

Poor quality of ANC

Poor Quality of ANC was reported to be a barrier to ANC uptake in 49 studies [ 53 , 59 ]. Women who believed they received low quality care were less likely to meet the WHO ANC recommendations [ 42 , 60 ]. Women cited lack of resources (e.g. ultrasound machines, providers etc.) [ 60 , 61 , 62 , 63 ], shortened hours of operation [ 27 , 60 ], long wait times [ 64 ], and a lack of trust in providers [ 65 , 66 ] as reasons for poor quality of care. Women also stated that healthcare providers were incompetent and had negative attitudes [ 43 , 50 ], which may explain the distrust they experienced [ 65 ].

Infrastructure and resources

Infrastructure or lack of resources was a factor reported to impact access to ANC in 11 studies. Studies found that women who perceived operational and infrastructure problems in their community (i.e., lack of electricity, running water, destroyed building infrastructure) were deterred from accessing ANC and faced poorer health outcomes as a result [ 61 , 67 ]. A study conducted by Mourtada et al. [ 63 ], found that as infrastructure destruction increased because of conflict, there was an associated decreased uptake of ANC.

Conflict & safety

Conflict and safety were reported as factors that directly impacted the uptake of ANC in nine and four studies [ 48 , 68 , 69 , 70 , 71 , 72 ], respectively. Women in zones of high conflict had poorer rates of ANC utilization. Due to prolonged conflict in FCAS, women felt unsafe or insecure travelling to ANC facilities, especially alone, and were therefore less likely to seek care as recommended [ 48 , 72 ]. This impact is intersectional as prolonged conflict negatively impacted education, fertility rate, availability of resources (e.g. machinery and providers), quality of care, and infrastructure, which in turn further decreased ANC utilization [ 48 , 68 , 69 ]. Increasing severity of conflict resulted in a decreased number of women in these areas meeting the WHO’s 2016 ANC recommendations. Finally, ANC was negatively impacted by a woman’s proximity to the conflict zone [ 70 ].

Parity, defined as the number of births a woman has had, was shown to be a factor that influenced ANC use in 21 studies. Women who did not have previous birth experience or who had low parity were more likely to initiate ANC early in pregnancy and to attend a greater number of ANC visits [ 73 ]. In contrast, women with higher parity were less likely to receive early ANC, attend the recommended number of visits, or meet the WHO’s ANC recommendations [ 17 , 74 , 75 ].

In 49 studies, women’s utilization of ANC was impacted by several other  factors (Table 2 ). One commonly cited other factor was husband’s education and employment, where women whose partners had higher levels of education or formal employment had increased usage of ANC [ 38 ]. Unwanted pregnancies [ 45 , 73 , 76 ], stigma from the community or family members [ 36 , 50 , 74 ], community members advising against using formal ANC services [ 21 , 77 ], use of traditional healers [ 47 , 77 ], lack of awareness and knowledge [ 31 , 38 , 78 , 79 ] and performance-based financing interventions [ 80 , 81 ] were additional factors associated with delayed and less frequent use of ANC.

This review identified 20 factors that impacted ANC utilization across 28 of the 37 regions classified as fragile and conflict-affected by the World Bank in 2020. This is the first review, to our knowledge, that examines ANC utilization in FCAS, exclusively. Overall, the 121 studies included demonstrate that women in FCAS are not meeting the WHO recommendations for ANC use. When compared to women worldwide, those living in FCAS are significantly less likely to seek ANC early in pregnancy or attend a total of four ANC visits, which makes them even less likely to achieve the WHO’s 2016 recommendation of eight ANC visits [ 82 ].

Although all 121 studies examined ANC in FCAS, only nine studies (7.43%) identified conflict as a direct barrier to accessing care. We posit that while conflict was not a frequently cited barrier, it may largely explain women’s poor uptake of ANC. For example, in some FCAS, healthcare facilities are attacked, practitioners may be kidnapped, killed, or forced to flee to urban areas to ensure safety, and clinics often lack necessary resources [ 83 ]. These events may explain why women experience poor quality of ANC and cannot find care facilities in rural areas [ 6 , 84 , 85 ]. Furthermore, in regions of conflict, women may more often be raped by members of the militia. This leaves women less likely to seek ANC out of fear of experiencing violence when travelling to a healthcare facility alone [ 86 , 87 ]. This discussion highlights the intersectional relationship between conflict and the four most cited factors impacting ANC [ 6 , 88 , 89 , 90 ], namely education, gender dynamics, socioeconomic status, distance and quality of ANC.

Education was the most commonly cited predisposing factor affecting ANC utilization. Specifically, lack of education resulted in decreased utilization of ANC, which is consistent with literature on maternal healthcare utilization. In FCAS, students and teachers may be killed or displaced due to targeted attacks or recruitment initiatives by military groups [ 91 ]. This prevents schools from re-opening and decreases the number of students enrolled should schools reopen [ 91 ]. Women are often prematurely forced out of the education system to care for their family after their fathers and brothers are recruited into the military or because of unwanted pregnancies, secondary to rape. Women who are unable to obtain higher levels of education are less likely to know the benefits of ANC or the recommendations regarding timing and frequency of use [ 12 , 82 , 88 , 92 ].

Gender dynamics, which encompasses gender-based violence and lack of autonomy, was cited 26 times as a predisposing factor that impacts initiation and frequency of ANC. In conflict-affected areas, the gender dynamics are strained, which puts women at higher risk of experiencing sexual violence and military sexual slavery [ 93 , 94 ]. Should a woman become pregnant secondary to rape, she must ask for permission and financial support from her husband before seeking out necessary maternal care [ 12 , 96 ]. Lack of autonomy to make decisions about contraception use [ 8 , 97 , 98 ] may also increase the likelihood of unwanted pregnancies, which is an other factor negatively impacting ANC use [ 6 , 97 , 99 ]. Women who are granted permission to seek ANC may still be unable to access it due to safety concerns associated with transport or lack of infrastructure in regions of high conflict.

Socioeconomic status, an enabling factor, was the most cited factor impacting ANC use. In regions of conflict, employment opportunities are limited, which makes it difficult for women to obtain the financial resources to pay the service and transportation fees associated with ANC. As a result, women may accept employment opportunities that put them at risk of physical and sexual harm, which may cause prenatal complications [ 95 ]. Should these women succeed in accessing timely and cost-effective ANC, they may not be able to afford the medications needed to ensure a healthy pregnancy. Women with lower socioeconomic status are also less likely to obtain higher levels of education, have financial autonomy, or be employed [ 100 ], which are all known to impact ANC utilization.

Distance was the fourth most commonly cited factor affecting the use of ANC. Distance is commonly thought of as the geographical space between a woman’s home and the nearest health facility [ 43 ]. In FCAS, conflict results in displacement of communities and the destruction of roads, transport vehicles and healthcare facilities, which all contribute to the increased distance between residential communities and healthcare facilities [ 101 , 102 ]. Interestingly, this review found that perceived distance, which is how far a woman believes the nearest ANC facility is to her, also impacted uptake of ANC. Perceived distance is influenced by weather conditions, physical terrain, lack of transportation, and fear of travelling to healthcare facilities alone [ 8 , 103 ]. Overall, distance, both real and perceived, to the nearest healthcare facility was found to impact ANC utilization and these distances may be increased in regions of conflict.

Poor quality of ANC was the second most commonly cited enabling factor impacting ANC uptake during pregnancy [ 6 , 104 ]. Women reported experiencing long wait times and receiving care from providers who were unfriendly and “inept” [ 30 ]. Conflict directly affects resource allocation and contributes to a lack of providers, equipment, and medical resources, which may explain the poor quality of care [ 83 ]. Pregnant women in FCAS are a vulnerable population who are often unaware of the benefits of ANC [ 38 ]. When a woman feels she received poor quality ANC, it may reinforce the idea that ANC has little benefit and deter her from seeking it in the future. As such, the shortage of healthcare resources in FCAS as a result of conflict makes it difficult to provide women with high quality care which appears to have negative impacts on ANC utilization.

In order to start addressing the predisposing barriers that women living in FCAS face when seeking ANC, policies must be changed and region-specific interventions are needed. First, policies that prioritize girls’ access to education should be implemented to ensure they can continue with their studies if they become pregnant. Second, educational curricula should be modified to teach students the importance of using contraceptives and seeking ANC. It is also an opportunity to target cultural beliefs that claim use of ANC early in pregnancy can bewitch a child and lead to miscarriage. Third, there is a need to increase the employment opportunities for women. This will allow women to have increased financial autonomy and higher socioeconomic status, which are both positively related to ANC utilization [ 40 ]. If girls are educated and women are employed, the gender dynamics that are prevalent in FCAS may also be redefined.

To mitigate enabling factors, governments should provide safe and affordable transportation, cost-effective ANC services, and incentives to ANC providers. Providing transportation will help women feel safer when travelling through regions of conflict to seek ANC. Similarly, subsidizing the costs associated with ANC will help alleviate the financial burdens that women of low socioeconomic status face when seeking care. Performance-based financing schemes, which have been implemented in some FCAS [ 105 ], may financially incentivize healthcare workers to provide high quality, patient-centered ANC. It would be important, however, to ensure that a portion of the money practitioners receive is used to hire additional personnel and purchase necessary equipment, which will further ameliorate the quality of care provided.

Addressing the barriers that prevent uptake of ANC will require a grassroots approach and cooperation from several stakeholders, which may be complex, costly, and lengthy. Local policy makers, women utilizing ANC within FCAS, and global organizations, such as the WHO, should collaborate and discuss the local context, the effect of conflict on utilization of ANC, and the factors that impact its uptake. This will maximize the potential to create effective change to increase women’s access to and utilization of ANC in FCAS.

Limitations

This review has some limitations that must be considered. First, we excluded studies not published in English, conducted prior to 2002, and for which the full text could not be accessed. Considering English is not the official language in many of the FCAS analyzed, this review may be missing relevant studies. Second, our search string was created according to the World Bank’s 2020 list of FCAS; however, studies from as early as 2002 are included in this review. As such, some of the analyzed data may have been collected at a time when the region was not classified as fragile and conflict-affected and may not represent the current barriers women in these regions are facing. Third, the included studies are heterogeneous and differ in their study design, sample size, and overall quality, which ultimately prevented us from carrying out a meta-analysis. Furthermore, many studies used self-reported data, which is subject to recall and social desirability biases. Despite these limitations, we used systematic methodologies informed by the PRISMA guidelines to conduct this review and have ensured the quality of the research findings by including studies that were rated as fair or good according to the NIH’s Quality Assessment Tools. Finally, this review does not include studies that utilized nationwide data (i.e., DHS and MICS), which may identify other factors that limit use of ANC. However, elimination of those studies was done to ensure that the data analyzed was specific to conflict-affected populations.

The findings of this systematic review demonstrate that women living in FCAS worldwide face many barriers to accessing ANC. These women are not meeting the WHO 2016 recommendations of eight ANC visits, which is contributing to the high MMR in these regions. Although conflict was not commonly identified as a barrier to accessing maternal health services, it is likely that the frequently cited factors, namely socioeconomic status, distance, education, quality of ANC, and gender dynamics, are exacerbated by the effects of conflict.

Future research

Our findings revealed that research on the factors that affect utilization of ANC is needed in the nine FCAS that are not represented in the included studies. Additionally, it is evident that the direct and indirect impacts of conflict on women’s healthcare utilization have not been well studied. Future research is urgently needed to understand how conflict impacts ANC uptake if we hope to lower the global MMR and achieve SDG 3.1 by 2030.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

• Antenatal care
• Fragile and conflict-affected situations

Maternal mortality rate

Sustainable development goal

World Health Organization

The World Bank. Population, total—Fragile and conflict affected situations. Published online 2018. https://data.worldbank.org/indicator/SP.POP.TOTL?locations=F1 .

Ranson K, Poletti T, Bornemisza O, Sondorp E. Conflict-affected fragile states. Published online 2007.

Bakrania S, Lucas B. The Impact of the financial crisis on conflict and state fragility in sub-Saharan Africa. 2009.

Bertocchi G, Guerzoni A. Growth, history, or institutions: What explains state fragility in sub-Saharan Africa? J Peace Res. 2012;49(6):769–83. https://doi.org/10.1177/0022343312452420 .

Article   Google Scholar  

Singh S, Orbinski JJ, Mills EJ. Conflict and health: a paradigm shift in global health and human rights. Confl Health. 2007;1(1):1. https://doi.org/10.1186/1752-1505-1-1 .

Article   PubMed   PubMed Central   Google Scholar  

Garry S, Checchi F. Armed conflict and public health: into the 21st century. J Public Health. 1990;2019:1–12. https://doi.org/10.1093/pubmed/fdz095 .

Bafilemba F, Prendergast J. Congo stories: battling five centuries of exploitation and greed. 2018.

Ziegler BR. Pregnancy in Peril : the impact of conflict on antenatal care and skilled birth attendant utilization in the Democratic Republic of the Congo and Burundi. Published online 2020.

The United Nations. Sustainable development goal. Published online 2015. https://sustainabledevelopment.un.org/sdg3 .

World Health Organization. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: executive summary. World Health Organization; 2019,12 p.

The World Bank. Maternal mortality ratio (modeled estimate, per 100,000 live births). Published online 2017. https://data.worldbank.org/indicator/SH.STA.MMRT .

Atuoye KN, Amoyaw JA, Kuuire VZ, et al. Utilisation of skilled birth attendants over time in Nigeria and Malawi. Glob Public Health. 2017;12(6):728–43. https://doi.org/10.1080/17441692.2017.1315441 .

Article   PubMed   Google Scholar  

Say L, Chou D, Gemmill A, et al. Global causes of maternal death: A WHO systematic analysis. Lancet Glob Health. 2014;2(6):323–33. https://doi.org/10.1016/S2214-109X(14)70227-X .

The World Health Organization. Maternal mortality. Published online 2019. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality .

The World Health Organization. WHO Antenatal care randomized trial: manual for the implementation of the new model. 2002.

The World Health Organization. WHO Recommendations on antenatal care for a positive pregnancy experience. 2016. https://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912-eng.pdf?sequence=1 .

Omer K, Afi NJ, Baba MC, et al. Seeking evidence to support efforts to increase use of antenatal care: a cross-sectional study in two states of Nigeria. BMC Pregnancy Childb. 2014. https://doi.org/10.1186/s12884-014-0380-4 .

Andersen RM. Andersen and Newman framework of health services utilization. J Health Soc Behav. 1995;36:1–10. https://doi.org/10.1111/pme.12756 .

Article   CAS   PubMed   Google Scholar  

National Heart Blood and Lung Institute. Study quality assessment tools. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools .

Neuman WL, Robson K. Basics of social researh. 3rd ed. Toronto: Pearson Canada; 2014.

Google Scholar  

Warri D, George A. Perceptions of pregnant women of reasons for late initiation of antenatal care: a qualitative interview study. BMC Pregnancy Childb. 2020. https://doi.org/10.1186/s12884-020-2746-0 .

Ndidi E, Oseremen I. Reasons given by pregnant women for late initiation of antenatal care in the Niger Delta, Nigeria. Ghana Med J. 2010. https://doi.org/10.4314/gmj.v44i2.68883 .

Kluckow H, Panisi L, Larui J, et al. Socio-demographic predictors of unintended pregnancy and late antenatal booking in Honiara, Solomon Islands. Aust N Z J Obstet Gynaecol. 2018;58(3):349–57. https://doi.org/10.1111/ajo.12782 .

Ebeigbe PN, Igberase GO. Antenatal care: a comparison of demographic and obstetric characteristics of early and late attenders in the Niger Delta, Nigeria. Med Sci Monit. 2005;11(11):529–32.

Edie GEHE, Obinchemti TE, Tamufor EN, Njie MM, Njamen TN, Achidi EA. Perceptions of antenatal care services by pregnant women attending government health centres in the Buea health district, Cameroon: a cross sectional study. Pan Afr Med J. 2015;21:1–9. https://doi.org/10.11604/pamj.2015.21.45.4858 .

Khanal V, da Cruz JLNB, Mishra SR, Karkee R, Lee AH. Under-utilization of antenatal care services in Timor-Leste: results from demographic and health survey 2009–2010. BMC Pregnancy Childb. 2015. https://doi.org/10.1186/s12884-015-0646-5 .

Benage M, Gregg Greenough P, Vinck P, Omeira N, Pham P. An assessment of antenatal care among Syrian refugees in Lebanon. Confl Health. 2015. https://doi.org/10.1186/s13031-015-0035-8 .

Anderson RM. Revisiting the behavioral model and access to medical care: Does it matter? J Health Soc Behav. 1995;36(1):1–10.

Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen’s behavioral model of health services use: a systematic review of studies from 1998–2011. Psycho-Soc Med. 2012. https://doi.org/10.3205/psm000089 .

Abimbola JM, Makanjuola AT, Ganiyu SA, Babatunde UMM, Adekunle DK, Olatayo AA. Pattern of utilization of ante-natal and delivery services in a semi-urban community of north-central Nigeria. Afr Health Sci. 2016;16(4):962–71. https://doi.org/10.4314/ahs.v16i4.12 .

Adam IF, Nakamura K, Kizuki M, Al Rifai R, Vanching U. Relationship between implementing interpersonal communication and mass education campaigns in emergency settings and use of reproductive healthcare services: Evidence from Darfur, Sudan. BMJ Open. 2015. https://doi.org/10.1136/bmjopen-2015-008285 .

Edu BC, Agan TU, Monjok E, Makowiecka K. Effect of free maternal health care program on health-seeking behavior of women during pregnancy, intra-partum and postpartum periods in Cross River State of Nigeria: a mixed method study. Maced J Med Sci. 2017;5(3):370–82. https://doi.org/10.3889/oamjms.2017.075 .

Ntambue AM, Malonga FK, Dramaix-Wilmet M, Ngatu RN, Donnen P. Better than nothing? Maternal, newborn, and child health services and perinatal mortality, Lubumbashi, democratic republic of the Congo: a cohort study. BMC Pregnancy Childb. 2016. https://doi.org/10.1186/s12884-016-0879-y .

De Allegri M, Ridde V, Louis VR, et al. Determinants of utilisation of maternal care services after the reduction of user fees: a case study from rural Burkina Faso. Health Policy. 2011;99(3):210–8. https://doi.org/10.1016/j.healthpol.2010.10.010 .

Bashour H, Abdulsalam A, Al-Faisal W, Cheikha S. Patterns and determinants of maternity care in Damascus. East Mediterr Health J. 2008;14(3):595–604.

CAS   PubMed   Google Scholar  

Ebeigbe PN, Gharoro EP. Obstetric complications, intervention rates and maternofetal outcome in teenage nullipara in Benin City, Nigeria. Trop Doct. 2007;37(2):79–83. https://doi.org/10.1258/004947507780609356 .

Nwakamma IJ, Erinmwinhe A, Ajogwu A, Udoh A, Ada-Ogoh A. Mitigating gender and maternal and child health injustices through faith community-led initiatives. Int J MCH AIDS. 2019;8(2):146–55. https://doi.org/10.21106/ijma.326 .

Failing F, Ripa P, Tefuarani N, Vince J. A comparison of booked and unbooked mothers delivering at the Port Moresby General Hospital: a case-control study. P N G Med J. 2004;47(3–4):174–80.

El-Kak F, Chaaya M, Campbell O, Kaddour A. Patterns of antenatal care in low-versus high-risk pregnancies in Lebanon. East Mediterr Health J. 2004;10(3):268–76.

Article   CAS   Google Scholar  

Oyetundeo and Elery. Factors influecing use of antenatal care and delivery services in Gwagwalada Area Council, Nigeria. Afr J Midwifery Women’s Health. 2014;8(4):195–202.

Alosaimi AN, Nwaru B, Luoto R, Al Serouri AW, Mouniri H. Using household socioeconomic indicators to predict the utilization of maternal and child health services among reproductive-aged women in rural Yemen. Glob Pediatr Health. 2019. https://doi.org/10.1177/2333794X19868926 .

Arnaert A, Ponzoni N, Debe Z, Meda MM, Nana NG, Arnaert S. Experiences of women receiving mhealth-supported antenatal care in the village from community health workers in rural Burkina Faso. Africa Digit Health. 2019. https://doi.org/10.1177/2055207619892756 .

Al-Mujtaba M, Cornelius LJ, Galadanci H, et al. Evaluating religious influences on the utilization of maternal health services among Muslim and Christian Women in North-Central Nigeria. BIOMED Res Int. 2016. https://doi.org/10.1155/2016/3645415 .

Telfer ML, Rowley JT, Walraven GEL. Experiences of mothers with antenatal, delivery and postpartum care in rural Gambia. Afr J Reprod Health. 2002;6(1):74–83. https://doi.org/10.2307/3583148 .

Sibanda EL, Bernays S, Weller IVD, Hakim JG, Cowan FM. “Well, not me, but other women do not register because”—Barriers to seeking antenatal care in the context of prevention of mother-to-child transmission of HIV among Zimbabwean women: a mixed-methods study. BMC Pregnancy Childb. 2018. https://doi.org/10.1186/s12884-018-1898-7 .

Somé DT, Sombié I, Meda N. How decision for seeking maternal care is made——a qualitative study in two rural medical districts of Burkina Faso. Reprod Health. 2013;10(1):1–6. https://doi.org/10.1186/1742-4755-10-8 .

Laing SP, Sinmyee SV, Rafique K, Smith HE, Cooper MJ. Barriers to antenatal care in an urban community in the Gambia: an in-depth qualitative interview study. Afr J Reprod Health. 2017;21(3):62–9.

Wilunda C, Scanagatta C, Putoto G, et al. Barriers to utilisation of antenatal care services in South Sudan: a qualitative study in Rumbek North County. Reprod Health. 2017. https://doi.org/10.1186/s12978-017-0327-0 .

Haggaz A, Ahmed S, Adam I. Use of prenatal care services in Darfur, Sudan. Int J Gynecol Obstet. 2008;103(3):252–3. https://doi.org/10.1016/j.ijgo.2008.06.010 .

Andrew EVW, Pell C, Angwin A, et al. Factors affecting attendance at and timing of formal antenatal care: results from a qualitative study in Madang, Papua New Guinea. PLoS ONE. 2014. https://doi.org/10.1371/journal.pone.0093025 .

Talhouk R, Mesmar S, Thieme A, et al. Syrian refugees and digital health in Lebanon: Opportunities for improving antenatal health. In: Conference on human factors in computing systems—proceedings. 2016;331–342. https://doi.org/10.1145/2858036.2858331 .

Tolefac PN, Halle-Ekane GE, Agbor VN, Sama CB, Ngwasiri C, Tebeu PM. Why do pregnant women present late for their first antenatal care consultation in Cameroon? Matern Health Neonatol Perinatol. 2017;3(1):1–6. https://doi.org/10.1186/s40748-017-0067-8 .

Okonofua F, Ogu R, Agholor K, et al. Qualitative assessment of women’s satisfaction with maternal health care in referral hospitals in Nigeria. Reprod Health. 2017;14(1):1–8. https://doi.org/10.1186/s12978-017-0305-6 .

Ifenne DI, Utoo BT. Gestational age at booking for antenatal care in a tertiary health facility in north-central, Nigeria. J Niger Med Assoc. 2012;53(4):236–9. https://doi.org/10.4103/0300-1652.107602 .

Rahmani Z, Brekke M. Antenatal and obstetric care in Afghanistan—a qualitative study among health care receivers and health care providers. BMC Health Serv Res. 2013. https://doi.org/10.1186/1472-6963-13-166 .

Alam N, Chowdhury ME, Kouanda S, et al. The role of transportation to access maternal care services for women in rural Bangladesh and Burkina Faso: a mixed methods study. Int J Gynecol Obstet. 2016;135:S45–50. https://doi.org/10.1016/j.ijgo.2016.09.003 .

Donmozoun TS, Sombie I, Meda N. What prevent women for a sustainable use of maternal care in two medical districts of Burkina Faso? a qualitative study. Pan Afr Med J. 2014;18:1–6. https://doi.org/10.11604/pamj.2014.18.43.2210 .

Wallace HJ, McDonald S, Belton S, et al. The decision to seek care antenatally and during labour and birth—Who and what influences this in Timor-Leste? A qualitative project exploring the perceptions of Timorese women and men. Midwifery. 2018;65:35–42. https://doi.org/10.1016/j.midw.2018.05.013 .

Shabila NP, Ahmed HM, Yasin MY. Women’s views and experiences of antenatal care in Iraq: a Q methodology study. BMC Pregnancy Childb. 2014. https://doi.org/10.1186/1471-2393-14-43 .

Chol C, Hunter C, Debru B, Haile B, Negin J, Cumming RG. Stakeholders’ perspectives on facilitators of and barriers to the utilisation of and access to maternal health services in Eritrea: a qualitative study. BMC Pregnancy Childb. 2018. https://doi.org/10.1186/s12884-018-1665-9 .

Alex M, Whitty-Rogers J. Experiences of pregnancy complications: Voices from central Haiti. Health Care Women Int. 2017;38(10):1034–57. https://doi.org/10.1080/07399332.2017.1350179 .

Lawry L, Canteli C, Rabenzanahary T, Pramana W. A mixed methods assessment of barriers to maternal, newborn and child health in gogrial west, south Sudan. Reprod Health. 2017;14(1):1–13. https://doi.org/10.1186/s12978-016-0269-y .

Mourtada R, Bottomley C, Houben F, Bashour H, Campbell OMR. A mixed methods analysis of factors affecting antenatal care content: a Syrian case study. PLoS ONE. 2019;14(3):1–24. https://doi.org/10.1371/journal.pone.0214375 .

Jallow IK, Chou YJ, Liu TL, Huang N. Womens perception of antenatal care services in public and private clinics in the Gambia. Int J Qual Health Care. 2012;24(6):595–600. https://doi.org/10.1093/intqhc/mzs033 .

Badal NF, Yusuf UA, Egal J, et al. With knowledge and support, women can attend antenatal care: the views of women in IDP camps in Somaliland. 2015.

Gure F, Yusuf M, Foster AM. Exploring Somali women’s reproductive health knowledge and experiences: results from focus group discussions in Mogadishu. Reprod Health Matters. 2015;23(46):136–44. https://doi.org/10.1016/j.rhm.2015.11.018 .

Ekabua J, Ekabua K, Njoku C. Proposed framework for making focused antenatal care services accessible: a review of the Nigerian setting. ISRN Obstet Gynecol. 2011;2011:1–5. https://doi.org/10.5402/2011/253964 .

Stojanovski K, Holla A, Hoxha I, Howell E, Janevic T. The influence of ethnicity and displacement on quality of antenatal care: the case of Roma, Ashkali, and Balkan Egyptian communities in Kosovo. Health Hum Rights. 2017;19(2):35–48.

PubMed   PubMed Central   Google Scholar  

Mullany LC, Beyrer C, Lee TJ, et al. Access to essential maternal health interventions and human rights violations among vulnerable communities in eastern burma. PLoS Med. 2008;5(12):1689–98. https://doi.org/10.1371/journal.pmed.0050242 .

Leone T, Alburez-Gutierrez D, Ghandour R, Coast E, Giacaman R. Maternal and child access to care and intensity of conflict in the occupied Palestinian territory: a pseudo longitudinal analysis (2000–2014). Confl Health. 2019. https://doi.org/10.1186/s13031-019-0220-2 .

Solanke BL. Factors associated with use of maternal healthcare services during the Boko Haram insurgency in North-East Nigeria. Med Confl Surviv. 2018;34(3):158–84. https://doi.org/10.1080/13623699.2018.1511358 .

Mugo NS, Dibley MJ, Damundu EY, Alam A. “The system here isn’t on patients’ side”—perspectives of women and men on the barriers to accessing and utilizing maternal healthcare services in South Sudan. BMC Health Serv Res. 2018. https://doi.org/10.1186/s12913-017-2788-9 .

Othman S, Almahbashi T, Alabed AAA, Abdulwahed A. Factors affecting utilization of antenatal care services in Sana’a city, Yeman. Malays J Public Health Med. 2017;17(3):1–14.

Oyewale TO, Mavundla TR. Socioeconomic factors contributing to exclusion of women from maternal health benefit in Abuja, Nigeria. Curationis. 2015;38(1):1–11. https://doi.org/10.4102/curationis.v38i1.1272 .

Teguete I, Maiga AW, Leppert PC. Maternal and neonatal outcomes of grand multiparas over two decades in Mali. Acta Obstet Gynecol Scand. 2012;91(5):580–6. https://doi.org/10.1111/j.1600-0412.2012.01372.x .

Ntambue AM, Dramaix-Wilmet M, Donnen P. Determinants of maternal health services utilization in urban settings of the Democratic Republic of Congo—a case study of Lubumbashi City. BMC Pregnancy Childb. 2012;12(1):66.

Doctor HV, Findley SE, Ager A, et al. Using community-based research to shape the design and delivery of maternal health services in Northern Nigeria. Reprod Health Matters. 2012;20(39):104–12. https://doi.org/10.1016/S0968-8080(12)39615-8 .

Truppa C, Leresche E, Fuller AF, et al. Utilization of primary health care services among Syrian refugee and Lebanese women targeted by the ICRC program in Lebanon: a cross-sectional study. Confl Health. 2019. https://doi.org/10.1186/s13031-019-0190-4 .

Kiruja J, Osman F, Egal JA, Essén B, Klingberg-Allvin M, Erlandsson K. Maternal near-miss and death incidences—frequencies, causes and the referral chain in Somaliland: a pilot study using the WHO near-miss approach. Sex Reprod Healthc. 2017;12:30–6. https://doi.org/10.1016/j.srhc.2017.02.003 .

Steenland M, Robyn PJ, Compaore P, et al. Performance-based financing to increase utilization of maternal health services: evidence from Burkina Faso. SSM Popul Health. 2016;2017(3):179–84. https://doi.org/10.1016/j.ssmph.2017.01.001 .

Ashir GM, Doctor HV, Afenyadu GY. Performance based financing and uptake of maternal and child health services in yobe sate, northern Nigeria. Glob J Health Sci. 2013;5(3):34–41. https://doi.org/10.5539/gjhs.v5n3p34 .

Ziegler BR, Kansanga M, Sano Y, Kangmennaang J, Kpienbaareh D, Luginaah I. Antenatal care utilization in the fragile and conflict-affected context of the Democratic Republic of the Congo. Soc Sci Med. 2020;262(July):113253. https://doi.org/10.1016/j.socscimed.2020.113253 .

Ramos Jaraba SM, Quiceno Toro N, Ochoa Sierra M, et al. Health in conflict and post-conflict settings: reproductive, maternal and child health in Colombia. Confl Health. 2020;14(1):33. https://doi.org/10.1186/s13031-020-00273-1 .

Filippi V, Ronsmans C, Campbell OM, et al. Maternal health in poor countries: the broader context and a call for action. Lancet. 2006;368(9546):1535–41. https://doi.org/10.1016/S0140-6736(06)69384-7 .

Kpienbaareh D, Atuoye KN, Ngabonzima A, et al. Spatio-temporal disparities in maternal health service utilization in Rwanda: What next for SDGs? Soc Sci Med. 2019;226(March):164–75. https://doi.org/10.1016/j.socscimed.2019.02.040 .

Sami S, Mayai A, Sheehy G, et al. Maternal and child health service delivery in conflict-affected settings: a case study example from Upper Nile and Unity states, South Sudan. Confl Health. 2020;14(1):34. https://doi.org/10.1186/s13031-020-00272-2 .

Kelly JT, Betancourt TS, Mukwege D, Lipton R, VanRooyen MJ. Experiences of female survivors of sexual violence in eastern Democratic Republic of the Congo: a mixed-methods study. Confl Health. 2011;5(1):25. https://doi.org/10.1186/1752-1505-5-25 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Daley P. Gender and genocide in burundi: the search for spaces of peace in the great Lakes region. 2008.

Baaz ME, Stern M. Why do soldiers rape? Masculinity, violence, and sexuality in the armed forces in the Congo (DRC). Int Stud Q. 2009;53(2):495–518. https://doi.org/10.1111/j.1468-2478.2009.00543.x .

Ezeh OK, Ogbo FA, Stevens GJ, et al. Factors Associated with the Early Initiation of Breastfeeding in Economic Community of West African States (ECOWAS). Nutrients. 2019. https://doi.org/10.3390/nu11112765 .

Bell S. The quantitative impact of conflict on education. 2011.

Uvin P. Life after violence: a people’s story of Burundi. 2008.

Manjoo R, McRaith C. Gender-based violence and justice in conflict and post-conflict areas. Cornell Int Law J. 2011;44:11–31.

Wirtz AL, Pham K, Glass N, et al. Gender-based violence in conflict and displacement: qualitative findings from displaced women in Colombia. Confl Health. 2014;8(1):10. https://doi.org/10.1186/1752-1505-8-10 .

Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partner violence during pregnancy: maternal and neonatal outcomes. J Womens Health. 2015;24(1):100–6. https://doi.org/10.1089/jwh.2014.4872 .

Gill MM, Ditekemena J, Loando A, et al. Addressing early retention in antenatal care among HIV-positive women through a simple intervention in Kinshasa, DRC: The Elombe “Champion” standard operating procedure. AIDS Behav. 2018;22(3):860–6. https://doi.org/10.1007/s10461-017-1770-1 .

Sano Y, Antabe R, Atuoye KN, Braimah JA, Galaa SZ, Luginaah I. Married women’s autonomy and post-delivery modern contraceptive use in the Democratic Republic of Congo. BMC Womens Health. 2018;18(1):4–10. https://doi.org/10.1186/s12905-018-0540-1 .

Tlapek SM. Women’s status and intimate partner violence in the Democratic Republic of Congo. J Interpers Violence. 2015;30(14):2526–40. https://doi.org/10.1177/0886260514553118 .

Mkandawire P, Atari O, Kangmennaang J, Arku G, Luginaah I, Etowa J. Pregnancy intention and gestational age at first antenatal care (ANC) visit in Rwanda. Midwifery. 2018;2019(68):30–8. https://doi.org/10.1016/j.midw.2018.08.017 .

White D, Dynes M, Rubardt M, Sissoko K, Stephenson R. The influence of intra familial power on maternal health care in Mali: perspectives of women, men and mothers-in-law. Int Perspect Sex Reprod Health. 2013;39(2):58–68. https://doi.org/10.1363/3905813 .

Ali R, Barra AF, Berg CN, Damania R, Nash JD, Russ J. Infrastructure in Conflict-Prone and Fragile Environments: Evidence from the Democratic Republic of Congo. Geneva: The World Bank; 2015. https://doi.org/10.1596/1813-9450-7273 .

Book   Google Scholar  

Mullany LC, Lee TJ, Yone L, et al. Impact of community-based maternal health workers on coverage of essential maternal health interventions among internally displaced communities in eastern Burma: The MOM project. PLoS Med. 2010. https://doi.org/10.1371/journal.pmed.1000317 .

Ebener S, Guerra-Arias M, Campbell J, et al. The geography of maternal and newborn health: the state of the art. Int J Health Geogr. 2015. https://doi.org/10.1186/s12942-015-0012-x .

Simkhada B, Van Teijlingen ER, Porter M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. J Adv Nurs. 2008;61(3):244–60. https://doi.org/10.1111/j.1365-2648.2007.04532.x .

Fakunle B, Okunlola MA, Fajola A, Ottih U, Ilesanmi AO. Community health insurance as a catalyst for uptake of family planning and reproductive health services: The Obio Cottage Hospital experience. J Obstet Gynaecol. 2014;34(6):501–3. https://doi.org/10.3109/01443615.2014.902044 .

Ibnouf AH, van den Borne HW, Maarse JA. Utilization of antenatal care services by Sudanese women in their reproductive age. Saudi Med J. 2007;28(5):737–43.

PubMed   Google Scholar  

Alenoghena IO, Isah EC, Isara AR. Maternal health services uptake and its determinants in public primary health care facilities in edo state, Nigeria. Niger Postgrad Med J. 2015;22(1):25–31.

Alhaidari T, Amso N, Jawad TM. Feasibility and acceptability of text messaging to support antenatal healthcare in Iraqi pregnant women: a pilot study. J Perinat Med. 2017;46(1):67–74. https://doi.org/10.1515/jpm-2016-0127 .

Balinska MA, Nesbitt R, Ghantous Z, Ciglenecki I, Staderini N. Reproductive health in humanitarian settings in Lebanon and Iraq: Results from four cross-sectional studies, 2014–2015. Confl Health. 2019. https://doi.org/10.1186/s13031-019-0210-4 .

Chi PC, Bulage P, Urdal H, Sundby J. A qualitative study exploring the determinants of maternal health service uptake in post-conflict Burundi and Northern Uganda. BMC Pregnancy Childb. 2015. https://doi.org/10.1186/s12884-015-0449-8 .

Findley SE, Doctor HV, Ashir GM. Reinvigorating health systems and community-based services to improve maternal health outcomes: case study from northern Nigeria. J Prim Care Community Health. 2015;6(2):88–99. https://doi.org/10.1177/2150131914549383 .

Franco LM, Diop FP, Burgert CR, Kelley AG, Makinen M, Simparae CHT. Effects of mutual health organizations on use of priority health-care services in urban and rural Mali: a case-control study. Bull World Health Organ. 2008;86(11):830–8. https://doi.org/10.2471/BLT.08.051045 .

Gao X, Kelley DW. Understanding how distance to facility and quality of care affect maternal health service utilization in Kenya and Haiti: a comparative geographic information system study. Geospat Health. 2019;14(1):92–102. https://doi.org/10.4081/gh.2019.690 .

Ibrahim HK, El Borgy MD, Mohammed HO. Knowledge, attitude, and practices of pregnant women towards antenatal care in primary healthcare centers in Benghazi, Libya. J Egypt Public Health Assoc. 2014;89(3):119–26. https://doi.org/10.1097/01.EPX.0000455673.91730.50 .

Jibril UN, Saleh GN, Badaki O, Anyebe EE, Umar A, Kamal A. Health education intervention on knowledge and accessibility of pregnant women to antenatal care services in Edu, Kwara State, Nigeria. Int J Womens Health Reprod Sci. 2018;6(2):154–60. https://doi.org/10.15296/ijwhr.2018.26 .

Larsen GL, Lupiwa S, Kave HP, Gillieatt S, Alpers MP. Antenatal care in Goroka: issues and perceptions. P N G Med J. 2004;47(3–4):202–14.

Maraga S, Namosha E, Gouda H, Vallely L, Rare L, Phuanukoonnon S. Sociodemographic factors associated with maternal health care utilization in Wosera. East Sepik Province. 2011;54(3–4):154–63.

CAS   Google Scholar  

Okonofua F, Ntoimo L, Ogungbangbe J, Anjorin S, Imongan W, Yaya S. Predictors of women’s utilization of primary health care for skilled pregnancy care in rural Nigeria. BMC Pregnancy Childb. 2018. https://doi.org/10.1186/s12884-018-1730-4 .

Rossier C, Muindi K, Soura A. Maternal health care utilization in Nairobi and Ouagadougou: evidence from HDSS. Glob Health Action. 2014;7:1–10. https://doi.org/10.3402/gha.v7.24351 .

Turan JM, Tesfagiorghis M, Polan ML. Evaluation of a community intervention for promotion of safe motherhood in Eritrea. J Midwifery Womens Health. 2011;56(1):8–17. https://doi.org/10.1111/j.1542-2011.2010.00001.x .

Vail J. Antenatal utilization, family planning and fertility preferences in Tari. P N G Med J. 2002;45(1–2):134–41.

Viswanathan K, Hansen PM, Hafizur RM. Can community health workers increase coverage of reproductive health services? J Epidemiol Community Health. 2012;66(10):894–900. https://doi.org/10.1136/jech-2011-200275 .

Adebangbe FT, Mturi AJ. Factors associated with the number of antenatal care visits among internally displaced women in northern Nigeria. Afr J Reprod Health. 2021;25(2):120–30.

Feng Y, Ahuru RR, Anser MK, Osabohien R, Ahmad M, Efegbere AH. Household economic wealth management and antenatal care utilization among business women in the reproductive-age. Afr J Reprod Health. 2021;25(6):143.

Laing SP, Guzek JM, Rassam DM, Ceesay IS, N’Dow JMO. Determinants of compliance with the World Health Organisation recommendations for pregnant women in an urban health centre in The Gambia. Afr J Reprod Health. 2020;24(3):24–32. https://doi.org/10.29063/ajrh2020/v24i3.3 .

Onalu C, Agwu P, Gobo B, Okoye U. Mortality experiences for women in riverine areas of the Niger delta and utilization of maternal health services. Health Soc Work. 2021;46(1):59–67. https://doi.org/10.1093/hsw/hlaa032 .

Oyovwe P, Woolhead G. Exploring health care professionals’ and women’s perspectives on the barriers to maternal health services: a qualitative study in Eku Town of Delta State, Nigeria. AIMS Public Health. 2021;8(1):154–71. https://doi.org/10.3934/publichealth.2021012 .

Somé A, Baguiya A, Coulibaly A, Bagnoa V, Kouanda S. Prevalence and factors associated with late first antenatal care visit in kaya health district, Burkina Fao. Afr J Reprod Health. 2020;24(2):19–26. https://doi.org/10.29063/ajrh2020/v24i2.2 .

Stanikzai MH, Wafa MH, Wasiq AW, Sayam H. Magnitude and determinants of antenatal care utilization in Kandahar City, Afghanistan. Obstet Gynecol Int. 2021;2021:e5201682. https://doi.org/10.1155/2021/5201682 .

Sui Y, Ahuru RR, Huang K, Anser MK, Osabohien R. Household socioeconomic status and antenatal care utilization among women in the reproductive-age. Front Public Health. 2021. https://doi.org/10.3389/fpubh.2021.724337 .

Kane S, Rial M, Kok M, Matere A, Dieleman M, Broerse JEW. Too afraid to go: fears of dignity violations as reasons for non-use of maternal health services in South Sudan. Reprod Health. 2018. https://doi.org/10.1186/s12978-018-0487-6 .

Lowe M, Chen DR, Huang SL. Social and cultural factors affecting maternal health in rural Gambia: an exploratory qualitative study. PLoS ONE. 2016. https://doi.org/10.1371/journal.pone.0163653 .

Meiksin R, Meekers D, Thompson S, Hagopian A, Mercer MA. Domestic violence, marital control, and family planning, maternal, and birth outcomes in Timor-Leste. Matern Child Health J. 2015;19(6):1338–47. https://doi.org/10.1007/s10995-014-1638-1 .

Ntoimo LFC, Okonofua FE, Igboin B, Ekwo C, Imongan W, Yaya S. Why rural women do not use primary health centres for pregnancy care: evidence from a qualitative study in Nigeria. BMC Pregnancy Childb. 2019. https://doi.org/10.1186/s12884-019-2433-1 .

Igboanugo GM, Martin CH. What are pregnant women in a rural Niger Delta community’s perceptions of conventional maternity service provision? An exploratory qualitative study. Afr J Reprod Health. 2011;15(3):59–72.

Mohamed-Ahmed R, Aziz MA, Walker R. Antenatal care in Sudan: a qualitative study into accessibility and quality of maternal health services in Khartoum. Int J Childb. 2018;8(2):77–86. https://doi.org/10.1891/2156-5287.8.2.77 .

Bayo P, Belaid L, Ochola E, et al. Maternal and neonatal health care service utilisation in the wake of active conflict and socio-economic downturn in Torit County, Republic of South Sudan: a multimethod locally driven study. Afr J Reprod Health. 2021;25(3s):30–42.

Akseer N, Bhatti Z, Rizvi A, Salehi AS, Mashal T, Bhutta ZA. Coverage and inequalities in maternal and child health interventions in Afghanistan. BMC Public Health. 2016. https://doi.org/10.1186/s12889-016-3406-1 .

Galadanci HS, Ejembi CL, Iliyasu Z, Alagh B, Umar US. Maternal health in Northern Nigeria—a far cry from ideal. BJOG Int J Obstet Gynaecol. 2007;114(4):448–52. https://doi.org/10.1111/j.1471-0528.2007.01229.x .

Merrell LK, Blackstone SR. Women’s empowerment as a mitigating factor for improved antenatal care quality despite impact of 2014 Ebola Outbreak in Guinea. Int J Environ Res Public Health. 2020;17(21):8172. https://doi.org/10.3390/ijerph17218172 .

Article   PubMed Central   Google Scholar  

Mutowo J, Yazbek M, van der Wath A, Maree C. Barriers to using antenatal care services in a rural district in Zimbabwe. Int J Afr Nurs Sci. 2021;15:100. https://doi.org/10.1016/j.ijans.2021.100319 .

Chittambo BR, Smith JE, Ehlers VJ. Community participation in providing antenatal services in Zimbabwe. Afr J Nurs Midwifery. 2003;5(1):9.

Edmond KM, Yousufi K, Anwari Z. Can community health worker home visiting improve care-seeking and maternal and newborn care practices in fragile states such as Afghanistan? A population-based intervention study. BMC Med. 2018. https://doi.org/10.1186/s12916-018-1092-9 .

Edmond KM, Foshanji AI, Naziri M. Conditional cash transfers to improve use of health facilities by mothers and newborns in conflict affected countries, a prospective population based intervention study from Afghanistan. BMC Pregnancy Childb. 2019. https://doi.org/10.1186/s12884-019-2327-2 .

Rudasingwa M, Soeters R, Basenya O. The effect of performance-based financing on maternal healthcare use in Burundi: a two-wave pooled cross-sectional analysis. Glob Health Action. 2017. https://doi.org/10.1080/16549716.2017.1327241 .

Christou A, Alam A, Sadat Hofiani SM, et al. Understanding pathways leading to stillbirth: the role of care-seeking and care received during pregnancy and childbirth in Kabul province, Afghanistan. Women Birth J Aust Coll Midwives. 2020;33(6):544–55. https://doi.org/10.1016/j.wombi.2020.02.012 .

Kim C, Tappis H, Natiq L, et al. Travel time, availability of emergency obstetric care, and perceived quality of care associated with maternal healthcare utilisation in Afghanistan: a multilevel analysis. Glob Public Health. 2021. https://doi.org/10.1080/17441692.2021.1873400 .

Jeremiah I, Kasso T, Oriji VK. Patients’ perception of antenatal care at the University of Port Harcourt Teaching Hospital. Niger J Med J Natl Assoc Resid Dr Niger. 2012;21(1):66–9.

King S, Passey M, Dickson R. Perceptions and use of maternal health services by women in rural coastal Madang Province. P N G Med J. 2013;56(1–2):5–13.

Hyzam D, Zou M, Boah M, et al. Health information and health-seeking behaviour in Yemen: perspectives of health leaders, midwives and mothers in two rural areas of Yemen. BMC Pregnancy Childb. 2020;20(1):404. https://doi.org/10.1186/s12884-020-03101-9 .

Grenier L, Suhowatsky S, Kabue MM. Impact of group antenatal care (G-ANC) versus individual antenatal care (ANC) on quality of care, ANC attendance and facility-based delivery: a pragmatic cluster-randomized controlled trial in Kenya and Nigeria. PLoS ONE. 2019;14(10):1–18. https://doi.org/10.1371/journal.pone.0222177 .

Currie S, Natiq L, Anwari Z, Tappis H. Assessing respectful maternity care in a fragile, conflict-affected context: observations from a 2016 national assessment in Afghanistan. Health Care Women Int. 2021. https://doi.org/10.1080/07399332.2021.1932890 .

Mourtada R, Bashour H, Houben F. A qualitative study exploring barriers to adequate uptake of antenatal care in pre-conflict Syria: low cost interventions are needed to address disparities in antenatal care. Contracept Reprod Med. 2021;6(1):17. https://doi.org/10.1186/s40834-021-00156-7 .

Udenigwe O, Okonofua FE, Ntoimo LFC, Imongan W, Igboin B, Yaya S. “We have either obsolete knowledge, obsolete equipment or obsolete skills”: policy-makers and clinical managers’ views on maternal health delivery in rural Nigeria. Fam Med Community Health. 2021;9(3):e000994. https://doi.org/10.1136/fmch-2021-000994 .

Perry HB, King-Schultz LW, Aftab AS, Bryant JH. Health equity issues at the local level: socio-geography, access, and health outcomes in the service area of the Hôpital Albert Schweitzer-Haiti. Int J Equity Health. 2007;6:1–10. https://doi.org/10.1186/1475-9276-6-7 .

Erismann S, Gami JP, Ouedraogo B, Revault D, Prytherch H, Lechthaler F. Effects of a four-year health systems intervention on the use of maternal and infant health services: results from a programme evaluation in two districts of rural Chad. BMC Public Health. 2021;21(1):2304. https://doi.org/10.1186/s12889-021-12330-2 .

Ekzayez A, Alhaj Ahmad Y, Alhaleb H, Checchi F. The impact of armed conflict on utilisation of health services in north-west Syria: an observational study. Confl Health. 2021;15(1):91. https://doi.org/10.1186/s13031-021-00429-7 .

Edmond K, Yousufi K, Naziri M. Mobile outreach health services for mothers and children in conflict-affected and remote areas: a population-based study from Afghanistan. Arch Child. 2020;105(1):18–25. https://doi.org/10.1136/archdischild-2019-316802 .

Nie J, Unger JA, Thompson S, Hofstee M, Gu J, Mercer MA. Does mobile phone ownership predict better utilization of maternal and newborn health services? A cross-sectional study in Timor-Leste. BMC Pregnancy Childbirth. 2016. https://doi.org/10.1186/s12884-016-0981-1 .

O’Keefe D, Davis J, Yakuna G, Van Gemert C, Morgan C. Formal and informal maternal health care: comparing the service provision of health facilities and village health volunteers in East Sepik Province. P N G Med J. 2011;54(3–4):147–53.

Ye M, Bagagan C, Millogo O. Use of mobile phone to promote governance and equity within the health system: experience of rural health district in Burkina Faso. J Heal Commun. 2016;1(3):1–11. https://doi.org/10.4172/2472-1654.100017 .

Ouedraogo C, Vosti S, Wessells K, Arnold C, Faye M, Hess S. Out-of-pocket costs and time spent attending antenatal care services: a case study of pregnant women in selected rural communities in Zinder, Niger. BMC Health Serv Res. 2021. https://doi.org/10.1186/s12913-020-06027-2 .

Samiah S, Stanikzai MH, Wasiq AW, Sayam H. Factors associated with late antenatal care initiation among pregnant women attending a comprehensive healthcare facility in Kandahar Province, Afghanistan. Indian J Public Health. 2021;65(3):298–301. https://doi.org/10.4103/ijph.IJPH_62_21 .

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This research was supported by a Canadian Graduate Scholarship-Masters from the Social Science and Humanities Research Council and an Ontario Graduate Scholarship.

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Detailed description of included studies in this systematic review (n = 121).

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Alibhai, K.M., Ziegler, B.R., Meddings, L. et al. Factors impacting antenatal care utilization: a systematic review of 37 fragile and conflict-affected situations. Confl Health 16 , 33 (2022). https://doi.org/10.1186/s13031-022-00459-9

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Book Review: Jen Silverman’s gripping second novel explores the long afterlife of political violence

This book cover image released by Penguin Random House shows “There’s Going to Be Trouble” by Jen Silverman. Penguin Random House via AP)

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Earlier this year a former member of the far-left Baader-Meinhof gang who spent decades in hiding was arrested by German police in connection with a string of crimes. It was just another example of the long afterlife of the anti-war movement of the late 1960s, which Jen Silverman explores in a brilliant, beautifully written new novel, “There’s Going to Be Trouble.”

Titling it after a line from an Allen Ginsberg poem — “My mind is made up there’s going to be trouble” — Silverman constructs an intricate, clever plot that braids together two separate stories connected by the main characters.

One takes place in 1968 when Keen, an apolitical grad student at Harvard, gets drawn into the takeover of a campus building because of his desperate love for Olya, one of the organizers. When the demonstration goes awry, he must live with the disastrous results for the rest of his lonely life as a chemistry professor and single dad. His one consolation is the daughter Olya bore him before going on the run. Everyone calls her Minnow, though she will grow up to embody the fierceness of her namesake Minerva, the Roman goddess of war.

The second storyline unfolds in 2018 during the yellow vest protests in France, where Minnow, now a 38-year-old teacher, has fled after being engulfed in a scandal in the U.S. whipped up by the religious right for helping an underage girl at her school obtain an abortion. In Paris, she gets caught up with a group of activists who, like their counterparts a half century earlier, are willing to go to virtually any length to challenge what they see as the inequities of French society.

Once again, love plays a decisive role. Just as her father fell head over heels for Olya, Minnow becomes enamored with Charles, the 23-year-old scion of a powerful French family whose father is a confidant of French President Emmanuel Macron. Though she has serious qualms about the 15-year age difference, she can’t keep her hands off him — and the feeling is mutual. Meanwhile, another brazen action is being planned that will also have deadly consequences.

Though the novel is a little slow to get off the ground and might have benefited from being 50 pages shorter, eventually it gathers unstoppable force as it moves toward a dramatic denouement that offers no easy conclusions. The questions Silverman poses about the ends and means of political violence are as relevant today as they were in the ’60s — or, for that matter, any era.

AP book reviews: https://apnews.com/hub/book-reviews

Book Review: Jen Silverman’s gripping second novel explores the long afterlife of political violence

In 1968, an apolitical grad student at Harvard gets drawn into the takeover of a campus building because he is in love with one of the organizers

Earlier this year a former member of the far-left Baader-Meinhof gang who spent decades in hiding was arrested by German police in connection with a string of crimes. It was just another example of the long afterlife of the anti-war movement of the late 1960s, which Jen Silverman explores in a brilliant, beautifully written new novel, “There’s Going to Be Trouble.”

Titling it after a line from an Allen Ginsberg poem — “My mind is made up there’s going to be trouble” — Silverman constructs an intricate, clever plot that braids together two separate stories connected by the main characters.

One takes place in 1968 when Keen, an apolitical grad student at Harvard, gets drawn into the takeover of a campus building because of his desperate love for Olya, one of the organizers. When the demonstration goes awry, he must live with the disastrous results for the rest of his lonely life as a chemistry professor and single dad. His one consolation is the daughter Olya bore him before going on the run. Everyone calls her Minnow, though she will grow up to embody the fierceness of her namesake Minerva, the Roman goddess of war.

The second storyline unfolds in 2018 during the yellow vest protests in France, where Minnow, now a 38-year-old teacher, has fled after being engulfed in a scandal in the U.S. whipped up by the religious right for helping an underage girl at her school obtain an abortion. In Paris, she gets caught up with a group of activists who, like their counterparts a half century earlier, are willing to go to virtually any length to challenge what they see as the inequities of French society.

Once again, love plays a decisive role. Just as her father fell head over heels for Olya, Minnow becomes enamored with Charles, the 23-year-old scion of a powerful French family whose father is a confidant of French President Emmanuel Macron. Though she has serious qualms about the 15-year age difference, she can’t keep her hands off him — and the feeling is mutual. Meanwhile, another brazen action is being planned that will also have deadly consequences.

Though the novel is a little slow to get off the ground and might have benefited from being 50 pages shorter, eventually it gathers unstoppable force as it moves toward a dramatic denouement that offers no easy conclusions. The questions Silverman poses about the ends and means of political violence are as relevant today as they were in the ’60s — or, for that matter, any era.

AP book reviews: https://apnews.com/hub/book-reviews

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John Barth, novelist who orchestrated literary fantasies, dies at 93

His comic novels and metafictional stories made him a giant of postmodernism.

John Barth, a novelist who crafted labyrinthine, fantastical tales that were at once bawdy and philosophical, placing him on the cutting edge of the postmodern literary movement, died April 2. He was 93.

His death was announced in a statement by Johns Hopkins University in Baltimore, where he was a longtime faculty member. The statement did not say where or how he died.

Mr. Barth was the author of about 20 books, among them the short-story collection “Lost in the Funhouse” (1968), a landmark of experimental fiction, and the comic novels “The Sot-Weed Factor” (1960) and “Giles Goat-Boy” (1966).

The former was included on Time magazine’s 2010 list of the 100 greatest English-language novels, and in 1973 Mr. Barth won a National Book Award for “Chimera,” a collection of three interrelated novellas that retold the mythical stories of Perseus, Bellerophon and Scheherazade. (Mr. Barth, not for the last time, appeared as a character in the work, making a cameo as a smiling genie who offers Scheherazade, or “Sherry,” fresh material for the stories she tells each night.)

Despite such acclaim, Mr. Barth’s books were sometimes criticized by peers as academic, pretentious and willfully obtuse. Where novelist John Updike offered praise, favorably comparing the marital dramas of “Chimera” to his own work about domestic discontent, writer Gore Vidal offered a scathing assessment: Mr. Barth’s books, he said , were “written to be taught, not to be read.”

Mr. Barth was, in fact, for many years a professor, teaching English and creative writing at his alma mater, Johns Hopkins. While he saw himself as a teacher as much as an author, he believed he was writing squarely in the tradition of storytellers such as Homer, Virgil and the imprisoned character of Scheherazade, whose storytelling prowess led her captor to spare her life.

He was, he said, a kind of literary arranger, enacting in literature what he had briefly done in his youth as an orchestrator for a jazz band.

“An arranger is a chap who takes someone else’s melody and turns it to his purpose,” Mr. Barth told the Paris Review in 1985. “For better or worse, my career as a novelist has been that of an arranger. My imagination is most at ease with an old literary convention like the epistolary novel, or a classical myth — received melody lines, so to speak, which I then reorchestrate to my purpose.”

Mr. Barth’s “reorchestrations” made him one of the foremost practitioners of postmodern literature, a movement that he helped define as the blending of straightforward storytelling techniques with the involuted, playful, frequently self-referential devices of modernists such as James Joyce and Samuel Beckett.

He was perhaps at his postmodern best — or worst, depending on one’s tastes — in “Lost in the Funhouse,” the title piece of his first story collection and a formative influence on the late David Foster Wallace .

The story shifts seamlessly between a traditional narrative — about a young boy’s trip to a hall of mirrors, located at a beach resort near Mr. Barth’s hometown on the Eastern Shore of Maryland — and observations on the nature of narrative itself.

A story, Mr. Barth seemed to suggest, was itself a kind of funhouse, one in which readers are made to believe that they are experiencing something real and true, rather than an artifice constructed out of words on a page.

“So far there’s been no real dialogue, very little sensory detail, and nothing in the way of a theme ,” the story’s narrator observes early in the piece. “And a long time has gone by already without anything happening; it makes a person wonder. We haven’t even reached Ocean City yet: we will never get out of the funhouse.”

John Simmons Barth, whose father owned a candy store, was born in Cambridge, on Maryland’s Eastern Shore, on May 27, 1930. He went by Jack, complementing his twin sister, Jill.

Mr. Barth played the drums in a local jazz group and briefly studied orchestration at Juilliard music school in New York before transferring to Johns Hopkins.

“As an illiterate undergraduate,” he once told the New York Herald Tribune, “I worked off part of my tuition filing books in the Classics Library at Johns Hopkins, which included the stacks of the Oriental Seminary. One was permitted to get lost for hours in that splendiferous labyrinth and intoxicate, engorge oneself with story.”

His interest was in narrative: sprawling epics such as “The Ocean of the Rivers of Story,” a multivolume work originally written in Sanskrit; Giovanni Boccaccio’s “The Decameron”; and Richard Burton’s translation of “The Thousand Nights and a Night,” which taught him how to pace epics and led to a fascination with stories within stories.

After graduating from Johns Hopkins with a bachelor’s degree in 1951 and a master’s in English in 1952, he planned a trilogy of short realist novels to address themes of suicide and nihilism.

The first two volumes — “The Floating Opera” (1956) and “The End of the Road” (1958) — were well-received but left Mr. Barth feeling unsatisfied. While teaching at Penn State, he later told The Washington Post, “I realized that realism was tying my hands.”

He responded by ditching plans for his third novel and — finding the playful, parodic voice that dominated most of his later work — launching himself to literature’s experimental fringe.

The result was “The Sot-Weed Factor,” a darkly funny, 800-page satire of Colonial Maryland that drew inspiration from a 1708 poem of the same name. In Mr. Barth’s telling, the poem’s author — a “rangy, gangling flitch called Ebenezer Cooke” — was a naive idealist grappling with the growing awareness that human existence is grim, fraught with violence and lacking in apparent purpose and meaning.

Written in the style of picaresque novels such as Henry Fielding’s “Tom Jones” and Laurence Sterne’s “Tristram Shandy,” the novel was “not for all palates,” the novelist and critic Edmund Fuller wrote in a review for the New York Times: “The plot itself is a parody in its incalculable complexity; a tissue of intrigue and counter-intrigue, ludicrous mock-heroic adventure, masquerades and confusions of identity.”

Mr. Barth’s follow-up, “Giles Goat-Boy,” was nearly as lengthy and even more outlandish. The book, its author once explained, was “a farcical allegory . . . of a goat sired by a virginal librarian on a computer.”

Improbably, it landed on the Times bestseller list for 12 weeks, helped along by praise from literary critics such as Robert Scholes, who hailed Mr. Barth as “a comic genius of the highest order” in a front-page review in the Times Book Review.

Mr. Barth continued his hyper-intellectual strain of writing in “Letters” (1979), a parody of epistolary novels that featured imagined correspondence between Mr. Barth and characters of his previous works, before turning to a more straightforward style in “Sabbatical” (1982).

The book was Mr. Barth’s most openly political work, and included about 20 pages of news clippings from the Baltimore Sun about John Paisley, a former CIA official whose body was discovered in the Chesapeake Bay in 1978, spawning conspiracy theories that he was silenced by the intelligence agency.

It also seemed to include elements of autobiography. Its protagonists were a husband and wife who, like Mr. Barth and his own wife, the former Shelly Rosenberg, sailed across the Chesapeake. (Mr. Barth, the owner of a 25-foot fiberglass sailboat, once told The Post that “one of the purposes of art is to give you boats you can’t afford.”)

A previous marriage, to Harriet Anne Strickland, ended in divorce. He had children, but information on survivors was not immediately available.

Mr. Barth received some of the most glowing reviews of his career for “The Tidewater Tales” (1987), a sequel of sorts to “Sabbatical.” The novel featured another husband and wife, this time with a male protagonist who appeared to be Mr. Barth’s literary opposite: a minimalist author who finds Shakespeare’s remark “Brevity is the soul of wit” to be “five-sixths too garrulous.”

The book, like his earlier work “Chimera,” featured a cameo from the mythical Scheherazade, whom Mr. Barth described as his “literary patron saint.”

“We like to imagine that our lives make sense, and storytelling is one way of ordering events,” he told the Times in 1982. “Of course, Scheherazade literally has to keep telling stories or she’s kaput. In a less dramatic way, that’s true of every writer in the world — you’re only as good as your next story.”