Intimate partner violence is a serious social problem and is preventable. Comprehensive sexuality education programmes can reduce gender violence
Intimate partner violence impacts women in vicious and myriad ways. In addition to physical injuries, it lowers their self esteem and reduces their decision-making abilities. But the significant role intimate partner violence (IPV) plays in lowering the utilisation of reproductive health services among women has not been given enough attention. Studies have shown that one in three women face IPV. Yet, less than one per cent of women, who experience IPV, seek help, although they face higher odds of induced abortion, miscarriage and stillbirth, lower odds of initiating immediate breastfeeding and their children have higher chances of dying before they turn two.
One of the prime reasons for this is that a majority of the women affected are convinced that they are responsible for the violence perpetrated against them. An acceptance of violence and justification of being beaten, kicked or slapped by a partner negatively impacts a woman's utilisation of health services and leads to lower chances of treatment. Women feel ashamed to speak about it openly and are embarrassed to seek help about their reproductive health problems, pointed a study on IPV in India, shared at the recently concluded Asia Pacific Conference on Reproductive and Sexual Health and Rights in Vietnam.
In cases where women are uneducated, poor and live in rural areas, stigma, coupled with health inequities, exacerbates the situation and widens the time gap between the act of violence and seeking of treatment. Inadequate financial resources and fear of social shame led rural women facing IPV in Tamil Nadu to finally seek treatment for prolapse 10 years after experiencing its first symptoms. So, when policy makers and heathcare providers apportion blame on women for not seeking services, is IPV ever considered as an important barrierIJ The answer lies in the lack of programmes that integrate IPV interventions focussed to increase access to health services for women experiencing violence.
Primary healthcare level is a good entry point for integration since frontline health workers are from the same community and, thus, easily accessible. Accredited social health activists (ASHAs), auxiliary nurse midwives (ANMs) and anganwadi workers, who are empathetic and trained, can be tapped. Among the three, ASHAs seem to be the best equipped not just because of their sheer numbers (nine lakh) but also because they are supposed to be trained in recognising signs of IPV. The National Health Mission manual for ASHAs lays out various ways to approach women facing violence. While the manual instructs ASHAs to try to resolve the problem through counselling or directing women to police stations and shelter homes, there is no guidance on how they can better her utilisation of sexual and reproductive health (SRH) services. The ASHA is not able to connect IPV to induced abortions, lack of immunisation compliance or refusal to initiate breastfeeding.
In 2017, a study was piloted with some ASHAs in rural Bihar by the Population Council and its partners to explore the feasibility of incorporating screening, identifying and referring women at risk of marital violence into the responsibilities of ASHAs. Although the intervention did not probe the linkages between IPV and low utilisation of SRH services, it found that frontline healthworkers were ideally placed to screen, counsel, refer and support women in their communities impacted by domestic violence.
While this strengthens the case for investing in ASHAs, as key implementers of improving SRH utilisation by women experiencing IPV, some innovative initiatives have shown that the power of mobile technology can be leveraged to do the same. Nurses and ANMs at 30 primary health centres run by the municipal corporation in Bengaluru have been trained to use a mobile application developed by Suneeta Krishnan, a social epidemiologist and Dimagi, a Boston-based technology company to identify women at risk of violence. They provide appropriate services when women come to these centres for antenatal and postnatal check-ups. Key here is to ensure a woman's bodily autonomy and enhance their uptake of SRH services.
A scale up of such good models seems to be a good solution. But it's not enough. There is a reason for the constant harping on the need for comprehensive sexuality education which teaches young minds gender equality among other things. The updated International Technical Guidance on Sexuality Education by the United Nations Educational, Scientific and Cultural Organisation (UNESCO) released in January this year places far greater emphasis on gender and rights. This is because there is enough evidence to show the damaging impact harmful gender norms and power inequalities has on sexual and reproductive health. Indian and international research has also indicated that comprehensive sexuality programmes lead to better outcomes in terms of gender equality and access to sexual and reproductive healthcare.
Care has to be taken that these programmes are designed to be age and culture appropriate. There is a body of evidence which suggests that well planned comprehensive sexuality education programmes can reduce gender violence and promote gender equality. That 16 per cent of deaths among women in India during pregnancy resulted from partner violence, is a grim reminder of the entrenched patriarchy and notions of masculinity. How many more women will have to die for not bringing enough dowry, slapped for not preparing tea on time, kicked for not producing a son... the list is endless. But women's wait for a life free of violence must not be.
(The writer is a senior journalist)