Jaya is pregnant with her fourth child. She works as a domestic help in a south Delhi colony. She must look for more work, but can barely juggle her hours. Her physical condition makes it doubly difficult. Her alcoholic husband does little to help. Often, Jaya reports for work with a black eye or welts on her arms and back. Does she want another child? No. Will she terminate the pregnancy? No. She does not want to risk her husband's wrath. "Of all the hardships that a woman may have to suffer, the worst is that of living with an abusive husband," she says.
Domestic violence cuts across economic strata. Anjali, for instance, is a graduate. Her husband is an executive in a multinational company. They have a son. Anjali describes her husband as 'short-tempered'. She has been slapped and punched a number of times for not being able to serve food on time or not dressing smartly enough. She wants another child and her husband agrees - on the condition that the child will be given away to his childless brother and sister-in-law. Anjali is afraid of protesting too much. She is depressed. As is typical among abused women, she holds herself guilty and even tries to defend her husband's behavior.
If Jaya is faced with unwanted pregnancy and prospects of increased physical hardship, Anjali's issue is one of denial and acute emotional distress - the range of consequences of intimate partner violence is vast and complex.
"The world over, one in four women is abused during pregnancy. In India, surveys have shown that in some districts, 16 per cent of deaths during pregnancy have been caused by domestic violence. Maternal mortality rates in India are amongst the highest in the world. Here, a woman dies every five minutes due to pregnancy- and childbirth-related complications. Again, for every death, there are 30 to 40 women whose health is adversely affected because of pregnancy and childbirth," says Dr Razia Pendse of the World Health Organization's (WHO) Regional Office for South-East Asia's reproductive health and research team.
Apart from poverty, illiteracy, and lack of proper healthcare, gender discrimination - of which violence is recognized as an extreme manifestation - is no doubt to blame for the condition. From domestic environments to conflict or war situations, a woman's encounter with violence can leave lifelong scars. Unwanted pregnancy, unsafe abortion, stillbirth and miscarriages, delayed antenatal and fetal injury, and low birth weight are common among victims of violence. Mental health problems, emotional distress and suicidal behavior are significantly higher among those who have experienced violence from their partners.
Fear of violence in itself limits a woman's ability to negotiate safe sex and leaves her exposed to HIV and other sexually transmitted infections. Forced sex is associated with a range of gynecological and reproductive health problems; brutal rape can result in fistula and perforated sexual organs.
It has also been established that children who witness marital violence face increased risk for emotional and behavioral problems, such as anxiety, depression, poor school performance, low self-esteem, disobedience, nightmares and physical health complaints. Such children are also more likely to act aggressively during childhood and adolescence. In rural Karnataka, India, a 1998 WHO community-based study on maternal mortality found that children of mothers who were beaten, received less food than other children, suggesting that these women could not bargain with their husbands on their children's behalf. Lower self-esteem, less mobility and less access to resources among domestic violence victims were other contributing factors.
In India, although we are in the midst of the Phase II (since 2005) of the Reproductive and Child Health (RCH) policy, reference to violence against women is conspicuously absent, except perhaps in the context of HIV/AIDS. At the national level, violence and reproductive health remain distinct - violence being regarded only as a legal and human rights issue. By its very nature, domestic violence is even more complex and rarely comes out in the open.
For over a decade now, health activists have been that demanding domestic and sexual violence be part of the national health policy. Says Dr Mira Shiva, health activist associated with Voluntary Health Association of India, "Sensitization should start from right from the medical college-level." Herself a gynecologist, she says that at medical schools there is no social context to the teaching of gynecology and obstetrics. The terms 'gender' or 'gender-specific violence' rarely get mentioned. Social work students, for instance, would know how to take care of rape victims better than a medical doctor.
Governments need to understand that maternal mortality and morbidity cannot be addressed fully if the issue of sexual and domestic violence is not taken into consideration. Vice versa, an appropriate way of dealing with violence and gender discrimination would be to address it through the RCH programme. Reproductive health services offer a strategic venue for offering support to women who have suffered violence. A visit to a reproductive health centre may be a woman's only chance to obtain help.
A WHO study on "Violence and Women's Health" in countries as diverse as Bangladesh, Japan, Serbia and Montenegro, Thailand and Brazil, released in November 2005, has shown that clients of reproductive health services would support such initiatives.
Earlier studies too have come to such conclusions. In a 1999 paper - 'Health sector initiatives to address domestic violence against women in Africa' - published by the University of Ghent, Belgium, Kim J says that in Cape Town, South Africa, 88 per cent of women attending a community clinic said they would welcome routine screening for violence. And a study by McNutt et al. in the Journal of the American Medical Association, 1999, found that both abused and non-abused women in the US favored screening for violence by their health providers.
Addressing violence against women in reproductive health settings may also be cost-effective. Reproductive health providers should be sensitized and trained to recognize and respond to violence, particularly during and after pregnancy, WHO recommends in its multi-country study. At a minimum, reproductive health providers should give women key messages about the unacceptability of violence, and ensure that women are receiving appropriate health services and are aware of the available forms of support, if they would like to take further action.
Although WHO's multi-country study does not include India, the situation in our country with respect to violence against women is similar, if not worse, to those of women elsewhere. There is a need to pay heed to the voices and recommendations and apply it in our own context.