Clinical and Medico-Legal Epidemiological Aspects of Domestic Violence against Women in Bangui (Central African Republic): About 150 Cases

Objective: evaluate domestic violence among women; identify the resulting injuries and the legal consequences. Methods: This was a 12-month cross-sectional study (From January to December 2017) of victims of domestic violence who were seen in the emergency room of Bangui Hospital Centres or who filed a complaint during the study period. All female victims of domestic violence with injuries requiring medical and surgical care had been retained. The data was entered and processed by the Epi info software. The Chi-squared test was used to compare significance level means at 0.05. Results: A total of 150 victims were included. Their average age was 29 years (range: 16 and 53 years). The length of conjugal life averaged 7.7 years (range: 1 and 32 years). The types of violence caused were psychological (68%), physical (99.3%), economic (51.3%), verbal


Introduction
Domestic violence is a major public health problem and an universal phenomenon that persists in all countries of the world [1][2][3][4]; but yet unrecognized and considered a tolerated or even accepted social phenomenon accompanied by significant health consequences [2, 5-10,]. In 2013 worldwide, nearly one third of women who had at least one relationship experienced physical and/ or sexual violence from their partner or ex-intimate partner [11]. Studies in Africa report that the trauma resulting from this violence plays a significant role in the trauma suffered by women [9,[12][13][14][15][16]. In the Central African Republic, no study has been carried out on the subject, although an analysis of society and hospital emergencies reveals a significant number of this scourge. Our study aims to describe the epidemiological aspects of domestic violence, identify the main types of domestic violence in Bangui, evaluate the physical consequences of domestic violence on women and the medical-legal management and make suggestions to limit them.

Methods
This was a cross-sectional study conducted from January 01 to December 31, 2017. Data were collected through a questionnaire that we submitted to any volunteer woman living in a couple and residing in Bangui. After consent, a clear explanation of the purpose of the study was given to each of the victims before the collection of information. The medical, surgical and gynecological emergency rooms of the Amitié Sino-Centrafricaine and Communautaire university hospitals as well as the police courts were the sites for data collection. We included all married or cohabiting women who had filed a complaint or consulted the emergency room following a physical assault by an intimate partner and who had injuries requiring medical and surgical management. Nonconsenting women and those not in a relationship were not included.
We looked for the following qualitative variables: educational level and occupation of the victim and the aggressor, the motive for the violence (jealousy, social problems), the place of the aggression (home, outside), the time of the aggression (day or night), the type of violence (physical, sexual, verbal, psychological, economic), the means used for the aggression (bare hands, projectile, firearm, knife), injuries, need for hospitalization, treatment, legal action, reason for legal action, reason for no legal action, conviction of the aggressor, use of psychoactive drugs by the aggressor. For the quantitative variables, the age of the victim and the aggressor, the length of marital life, the frequency of violence and the total work incapacity were collected.
The research was authorized by the Faculty of Health Sciences (FACSS) in Bangui and the consultation of judicial files was facilitated by the Ministry of Justice of the Central African Republic. The information collected from the victims was confidential. The consent of the victims was a prerequisite for entry into the study. The data collected was entered and analyzed using Epi-info 3.5.1 software. Results were presented in tabular form. We used the Chi 2 test for comparison of means for a significance level less than or equal to 0.05.

Results
During the study period, 150 victims of domestic violence were retained. The average age of the women was 29 years (±7.29) with extremes of 15 and 55 years. The age range of 25 to 35 years dominated the series (46%). Those with low educational level were few (22.7%). Professional women and housewives dominated (57.3%). Only 10% of the victims were employed in the public or private sector.
The average age of the aggressors was 36 years (±8.9). Spouses in the 30-40 age group represented 46.5%. The abusers had a high school education in 58%. Only 5.3% of the perpetrators had a low level of education (primary). All socioprofessional categories were observed among the aggressors, with a predominance of informal activities (42.7%).
The aggression was observed in 88% of the cases in common-law unions (concubinage). Couples lived under the same roof in 75% of cases. Couples with a marital life span of 1-5 years dominated in 43.3% of cases. Alcoholism of the aggressor spouse was found in 74 cases, i.e. 49% of the cases. Jealousy was reported as the motive for the aggression in more than half of the cases (56%), followed by social problems (custody of the child after separation, unwanted pregnancy, precariousness). From the 150 assaults recorded, 106 (71%) occurred at night. The assaults were physical in almost all cases (99.3%). Physical assault was followed by rape in 12.1% of cases. The aggressors did not use blunt objects other than blows to the head, fists and feet (74.7%). Recidivism was observed in 86% of the victims. The head was the area of the body where the injuries were located (60%). Pregnant women were concerned (16%). Their aggression led to 6 cases of abortion. The lesions observed required medical attention in the majority of cases (72.7%). Hospitalization was necessary for 24 victims (16%).
The injuries caused resulted in an ITT in 57.3% of cases. Legal action was taken by 72 women (48%). The occurrence of abortion during pregnancy was the main reason for legal action (p=0.005). Punishment of the spouse was the main expectation that motivated the victim for legal action (52.78%). Out-of-court settlement was the preferred method of settlement for victims (70.5%). Dismissal was the judicial conclusion of 50 cases (69%) of complaints. We observed 14 cases of firm imprisonment of the aggressors.
During the study, the 51 victims who were severely assaulted had spouses with little education (non-university level). This finding was statistically significant (p=0.03). TBI, abortion cases, and cohabitation with spouse were statistically related to the use of justice (p=0.00). 116 women (77.33%) did not have a higher level of education. Among them, 52 were victims of violence with a frequency higher than 5 (p=0.01).

Discussion
This was a cross-sectional study conducted at several data collection sites. Also, some NGOs working with victims of violence were less cooperative. This could be a selection bias limiting the extent of the phenomenon during the study period.
The phenomenon is observed in young subjects in their thirties. This is the age of sexual activity and therefore of problems in relationships. The other studies that were carried out had the same average age of 30 years [17,18]. The low intellectual level of one of the couple is a risk factor for domestic violence in our series (Table 1). This is the same finding made by Mc Closkey, et al. [19] in their study. The study by Boufettal, et al. [20] reported 71% of the women were illiterate. On the other hand, for François, et al. [21], the level of education and the socio-cultural categories are not correlated with domestic violence.  The victims in our series work in informal jobs in 30% of cases. These jobs are often small and casual, making the victims dependent on their male abusers. The work of Nyamwasa, et al. [3] reports the same proportion of victims without a paid profession at 32.9%. The abuser's low level of education was also related to domestic violence (p=0.03). The study by Soumah, et al. [22], carried out in Senegal, reported a lower proportion than ours. The low literacy rate in the Central African Republic could explain this difference in proportion. However, the high level of education of the spouses does not prevent the existence of conjugal violence in the couple.
The informal sector is the dominant occupation of aggressors (42%) in our series (Table 2), followed by civil servants (40%). Pupils, students and those with no profession represent only 18%. The pressure generated by these professions would make spouses nervous when they return home [2-4, 14, 23, 24]. The predominance of unemployment in CAR would explain the high rate of the informal sector.   [3], 56.8% of cases in their series were associated with the spouse's alcoholism. For Jellali, et al. [7], 95% of the assault cases in their study were related to alcoholism. Daily alcohol consumption by the partner is a predictor of physical violence in the couple [25]. Alcohol abuse lead to a loss of self-control and can ineluctably push to violent aggression.
Our study reports a predominance of benign lesions (ecchymosis, contusion, superficial wounds, diffuse pain). These lesions account for 56.7% of the series (Table 3). Our results are close to those in the literature. Gastineau, et al. [23] in their series in Antananarivo reported 69% of haematomas and wounds with bleeding. Bah, et al. [2] in Conakry in 58 cases reported 96.55% of contusions and ecchymoses in their series.

Items
Number Percentage n=150 %  22.7% of ocular injuries were noted in our study ( Table 3). The study by Atipo-Tsiba, et al. [18] on 15 cases corroborates these results. The head being the most affected region of the body, this may explain the high frequency of ocular lesions.

Site of the lesions
Our series reported 8% of fractures (Table 3). However, Gastineau, et al. [23] reported 15% of fractures or sprains in their series in Antananarivo and Atipo-Tsiba, et al. [18] in Brazzaville on 15 cases found 33.3% of fractures. Other lesions were also reported in our study: dental lesions (7.3%); penetrating wounds (5.3%). However, we did not find any data in the literature about these lesions.
In our series, 24 women were pregnant, i.e. 16% (Table 3). Soumah, et al. [22] reported 12.9% of pregnant women in their series. We recorded 6 cases of abortion following physical violence (25%). However, Boufettal, et al. [20] reported 44% of abortions in their study in Casablanca. This difference could be explained by the composition of their series (pregnant women only).
Our series reports 48% of complaints. In 30.6% of the cases (22) the aggressors were convicted and 69.4% of the cases were not followed up. In terms of convictions, 63.6% were for imprisonment and 36.4% for compensation. Our results are close to those of Nyamwasa, et al. [3] in Kigali where 47% of the suspects were arrested and 25% were imprisoned. However, Soumah, et al. [22] in their series in Dakar reported that 9.4% of battered women had filed a complaint. This low rate of legal recourse is explained by the predominance of family resolution of problems (amicable settlement 36.7%). In addition, some women mentioned shame (8%), others fear (6%) and some lack of confidence in the justice system (1.3%) (

Conclusion
Domestic violence exists with serious health consequences. The majority of the victims are young and have been married for less than 10 years. The low level of education of the spouse represents a factor of gravity of the injuries. The induced incapacity, the occurrence of an abortion motivate the recourse to justice. They have an impact on the family and society in general. The seriousness of this violence remains underestimated. Prevention and care for victims are still insufficient. Spouses must learn to resolve conflicts in their relationship in a non-violent manner.