Study design and data source
This cross-sectional study used the 2015–16 Malawi Demographic and Health Survey (MDHS). The MDHS collected data from 19 October 2015 to 17 February 2016 using a two-stage stratified sampling method. The first stage involved selecting standard enumeration areas (SEAs) from the 2008 Malawi Population and Housing Census (i.e., sampling frame) and household listing from those SEAs. The second stage involved the selection of households from the sampled SEAs using equal probability systematic selection. The current study was restricted to women in a union (married or living with a partner) at the time of the survey, who had a live birth in the 5 years preceding the survey, whose partner was interviewed, and who had complete information.
Main independent variables
The main independent variable was IPV, calculated using a total of 13 items. The 13 items fell under three categories of physical, sexual, and emotional violence. “Appendix 1” shows the specific 13 items that were assessed. A respondent reported to have ever experienced any of the forms of violence under each type of violence (i.e., at least in one type of violence under the 13 items as seen in “Appendix 1”) was coded as having IPV; otherwise, no violence. This categorization was defined as the overall IPV. In addition to the composite variable, physical, sexual, and emotional violence were also considered and assessed as separate independent variables.
Dependent variables
The study considered five key maternal health care services as dependent variables relating to the most recent birth in the previous 5 years before the survey, namely; the number of ANC visits, the timing for first ANC, place of delivery (or institutional delivery), skilled assistance at delivery, and PNC within 2 days of delivery. The use of these services was self-reported by the participants.
ANC visits
According to WHO recommendations, the number of ANC visits was categorized into two levels: adequate (8 or more) and inadequate (fewer than 8) [20].
Timing for first ANC
The timing of first ANC visit was categorized as early (first trimester), and late (second/third trimester) [21].
Institutional deliveries
Institutional deliveries defined as births that occurred at any level of health facility (i.e., government hospital/government health centre/government health post or outreach/ another public sector); private sector (private hospital or clinic/Christian Health Association of Malawi (CHAM) or Mission hospital/CHAM or Mission health centre/Banja La Mtsogolo/other private medical sectors) [22]. Those that delivered at home were regarded having were defined as “home deliveries”.
Skilled assistance during delivery
A delivery was said to have had occurred with skilled assistance if the birth was assisted by doctors, clinical officers, medical assistants, nurses, and midwives, while those delivered through the help of traditional birth attendants (TBAs), relative/friends were defined as unskilled assistance [22].
PNC health check within 2 days of delivery
PNC health check for the woman within 2 days after delivery by skilled professionals (skilled professionals as described above) [22].
Covariates
Based on their importance in the literature on the outcomes under consideration [5, 6, 12], the following variables were included in the analysis: woman’s age in years (15–24, 25–34, and ≥ 35), woman’s educational level (no formal education, primary, and secondary and tertiary), household wealth calculated using principal component analysis by scoring household items and aggregating the scores into rich (upper 40%), middle (middle 20%) and poor (lower 40%), region (northern, central, and southern), residence (urban or rural), media exposure (those reporting to read newspapers, watch television, and listen to radio at least once a week categorized as yes otherwise, no), perceived distance to health facility (problem vs no problem), partner age in years (15–29, 30–44, and ≥ 45), and partner’s educational level (no formal education, primary, and secondary and tertiary).
Statistical analysis
Weighted frequencies and percentages were presented for the study characteristics. Multivariable logistic regression models were used to test the association between IPV and selected maternal health care services using the “svy” command to account for sampling weights and survey design. Adjusted odds ratios (aOR) and 95% confidence intervals (CIs) with a significance level set at p < 0.05 were reported. All analyses were performed using Stata version 15 (Stata Corp, College Station, TX, USA).
Ethical consideration
The DHS measure program provided approval to use the 2015–16 MDHS data, and the data is publicly available on their website http://dhsprogram.com/data/available-datasets.cfm. The MDHS survey protocol was approved by the Malawi National Health Sciences Research Committee and ICF Macro institutional review board. Before each interview was conducted, a verbal informed consent was sought by each interviewer reading a prescribed statement to the respondent and recording in the questionnaire whether or not the respondent consented (or provided assent on behalf of minors). Then the interviewer signed his or her name attesting to the fact that he/she read the consent statement to the respondent. The method of collecting consent has been standardized in the DHS survey to ensure consistency as some participants are not able to write.