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Intimate partner violence and pregnancy spacing: results from a meta-analysis of individual participant time-to-event data from 29 low-and-middle-income countries
  1. Lauren Maxwell1,
  2. Arijit Nandi1,2,
  3. Andrea Benedetti1,
  4. Karen Devries3,
  5. Jennifer Wagman4,
  6. Claudia García-Moreno5
  1. 1 Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Quebec, Canada
  2. 2 Institute for Health and Social Policy, McGill University, Montréal, Quebec, Canada
  3. 3 Department of Global Health and Development, Social and Mathematical Epidemiology Group and Gender Violence and Health Centre, London School of Hygiene & Tropical Medicine, London, UK
  4. 4 Division of Global Public Health, Department of Medicine Central Research Services Facility (CRSF), University of California, San Diego, California, USA
  5. 5 Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
  1. Correspondence to Dr Lauren Maxwell, McGill University; lauren.maxwell{at}


Introduction Inadequately spaced pregnancies, defined as pregnancies fewer than 18 months apart, are linked to maternal, infant, and child morbidity and mortality, and adverse social, educational and economic outcomes in later life for women and children. Quantifying the relation between intimate partner violence (IPV) and women’s ability to space and time their pregnancies is an important part of understanding the burden of disease related to IPV.

Methods We applied Cox proportional hazards models to monthly data from the Demographic and Health Surveys’ Reproductive Health Calendar to compare interpregnancy intervals for women who experienced physical, sexual and/or emotional IPV in 29 countries. We conducted a one-stage meta-analysis to identify the periods when women who experienced IPV were at the highest risk of unintended and incident pregnancy, and a two-stage meta-analysis to explore cross-country variations in the magnitude of the relation between women’s experience of IPV and pregnancy spacing.

Results For the one-stage analysis, considering 52 959 incident pregnancies from 90 446 women, which represented 232 394 person-years at risk, women’s experience of IPV was associated with a 51% increase in the risk of pregnancy (95% CI 1.38 to 1.66), although this association decreased over time. When limiting our inference to unintended pregnancies that resulted in live births, women’s experience of IPV was associated with a 30% increase in the risk of unintended pregnancy (95% CI 1.25 to 1.34; n=13 541 pregnancies, 92 848 women, 310 319 person-years at risk). In the two-stage meta-analyses, women’s experience of IPV was associated with a 13% increase in the probability of incident pregnancy (95% CI 1.07 to 1.20) and a 28% increase in the likelihood of unintended pregnancy (95% CI 1.19 to 1.38).

Conclusions Across countries, women’s experience of IPV is associated with a reduction in time between pregnancies and an increase in the risk of unintended pregnancy; the magnitude of this effect varied by country and over time.

  • Intimate partner violence
  • maternal and child health
  • low-and-middle-income countries
  • interpregnancy intervals
  • unintended pregnancy
  • birth spacing
  • survival analysis
  • Cox proportional hazards models
  • meta-analysis

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Handling editor Seye Abimbola

  • Contributors Conceived and designed the experiments: LM and AB. Performed the experiments: LM. Analysed the data: LM. Contributed reagents/materials/analysis tools: LM. Wrote the first draft of the manuscript: LM. Contributed to the writing of the manuscript: LM, AN, AB, KD, JW and CG-M. Agree with the manuscript’s results and conclusions: LM, AN, AB, KD, JW and CG-M. All authors have read and confirmed that they meet the ICMJE criteria for authorship.

  • Funding Funding support was provided by the Canadian Institutes of Health Research Operating Grant, ‘Examining the impact of social policies on health equity’ (ROH-115209), and by the Harry Frank Guggenheim Foundation Dissertation Fellowship to LM. AN is supported by the Canada Research Chairs Program. These funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

  • Competing interests None declared.

  • Ethics approval The Institutional Review Board (IRB) of ICF International reviewed the MEASURE DHS Project Phases III and IV, which encompass the surveys included in this analysis. ICF International’s IRB complies with the US Department of Health and Human Services requirements for the protection of human subjects (45 Code of Federal Regulations 46). ICF International also secured ethics approval for each survey from individual countries’ national ethics committees. Given that this analysis used deidentified, publicly available data, the research protocol was deemed exempt from review by the Research Ethics and Compliance Institutional Review Board at McGill University in Montréal, Canada, where this analysis was conducted.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data sets supporting the conclusions of this article are available in the Demographic and Health Surveys Program data repository,