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Integrate survivor support and assistance into reproductive health programmes

  • Most women will seek some form of reproductive health service (e.g. family planning, maternal and child health care, routine gynecological care, abortion services and STI (including HIV) counseling, testing and treatment) at some time in their life and there are clear links between sexual and reproductive health and violence. Providers serve a sexually active population; pre-natal care services in particular tend to have the highest national coverage, and are most apt to reach highly marginalized and vulnerable women and girls.
  • The linkages between violence against women and girls and sexual and reproductive health risks are bi-directional.  That is, gender inequalities and violence against women and girls are among the key factors in reproductive health vulnerabilities for women and girls, while sexual and reproductive health issues such as unintended pregnancy can increase violence against women and girls risks and serve to compound the effects of other aspects of gender discrimination.
  • In general, reproductive health programmes should follow the steps outlined in Section A: Build institutional capacity to address violence against women and girls in hospitals, health clinics, and other primary and secondary health facilities when integrating violence against women programming into their services.  At a minimum, implementation of quality violence against women and girls screening and counseling, as well as referrals to appropriate services for follow-up, are key components in the constellation of reproductive health interventions needed to address violence against women and girls.

Case Study: Manuela Ramos Engages Community-based Women’s Groups in Peru to Better Serve their Needs

Manuela Ramos launched ReproSalud in 1995 as a USAID-funded rural reproductive health programme. ReproSalud used a form of participatory rural appraisal, by working with community-based women's groups (such as mothers' clubs) to identify women's reproductive health needs through "auto-diagnosis workshops." Following these workshops, they held community meetings to design strategies to address the needs that women identified. ReproSalud ultimately responded to a range of health, social and economic concerns. Domestic violence and forced sex within marriage repeatedly emerged as themes and became a focus of many activities, including workshops for women and men on gender. ReproSalud also established a microcredit programme for women.  By 2002, ReproSalud had reached over 123,000 women and 66,000 men.

Evaluators gathered baseline and midpoint data in 70 intervention sites and 25 control sites, including: a) baseline and midterm surveys among a random sample of households (baseline n =4,099 women, 3,192 men; midterm n = 3450 women, 3193 men); b) service utilization statistics at local health facilities; and c) semi-structured interviews with women, men, youth, village leaders, health officials, and local authorities. The evaluation measured individual-level, family-level, and community-level "empowerment outcomes." Family level outcomes included changes in levels of domestic violence, satisfaction regarding sexuality, shared decision-making, and women's social and geographic mobility. Quantitative findings were complemented with extensive qualitative data.

The survey found that gender-equitable attitudes and practices increased significantly in both intervention and control communities (14 out of 15 indicators versus 12 out of 15 indicators). The use of reproductive health services also rose 100-400% during a one-year period in intervention sites, compared to 39-51% in control communities.  Evaluators noted that the project coincided with a period of strong investment by the Ministry of Health, which made it difficult to isolate the effects of the project. However, differences between the intervention and control sites were more pronounced in the qualitative data. Those findings suggested that ReproSalud had produced dramatic changes in social relations and men's behaviour through the communities.  Respondents spoke at length about decreased alcohol consumption, domestic violence, and forced sex in all intervention villages studied.

 

Source: excerpted from Morrison, Ellsberg, and Bott, 2004, and also accessed through Bott, n.d.

 

  • Addressing violence against women and girls through reproductive services is also an essential prevention strategy. Reproductive health services are ideal channels to detect women and girls experiencing violence or at high risk of violence, and counsel or refer them to prevent a first experience of violence, or work with them to prevent recurrence.

 

Example: The International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR) and the Asociacion Civil de Planificacion Familiar (PLAFAM) in Venezuela used three strategies to address violence against women and girls within their reproductive health services. The first strategy was training staff. Providers were trained to ask questions to assess a survivor’s current safety and assist with the development of a safety plan. Additionally, clinicians were trained to: recognize signs of violence through examining marks on the body; be responsive if a woman decides to disclose that she is being abused; and to provide related counseling and referrals.  The second strategy was developing materials for clients on violence and sources of support, including the Institutional Directory of Gender-based Violence Service Providers. The third and final strategy was collaborating with community alliances to create a law outlawing violence against women.

The systematic screening practices revealed that over one-third of new clients were identified as having experienced abuse compared to only 7 percent previously (Guedes et al./Population Council, 2002b). 

PLAFAM has been recognized by the World Health Organization in 2000 and  IPPF in 2003 and 2010 for its technical assistance to three Latin American countries working to integrate services for survivors of gender-based violence in sexual and reproductive health.

See the full report in English.

 

  • In addition, when men or boys accompany their partners or wives to reproductive health services, it is an important opportunity to involve them in reducing risks and prevention of violence against women and girls (as long as women and girls agree with their involvement).  For more information on strategies to engage men and boys in ending violence against women, see the full module.

 

1.    Family Planning services

  • Many family planning services have clients who have been exposed to violence against women and girls (Watts and Mayhew, 2004).   Women/girls having unprotected sex may do so because they are subject to threats, coercion, physical violence, or sexual violence. Addressing violence against women and girls will help make family planning programmes more effective.  If violence is stopped, women will have a wider range of contraceptive methods to choose from, might have greater success in negotiating with male partners to use condoms, and in general will be empowered to communicate more with their partners on equal footing regarding reproductive choices. 
  • One sign of high risk would be when screening determines that women/girls are having unprotected sex when they do not want children, women who experience intimate partner violence may have less control over use of contraception (Cripe et al., 2008).  Survivors who have access to family planning services should have the option of hormonal injections in order to use contraception without the knowledge of partners (Gee et al., 2009).
  • Infertility services should also screen for violence against women and girls. In most societies fertility is highly prized, and in many, women suffering from infertility may be subject to violence from their husbands, or the husbands’ family (Yildizhan et al., 2009).
  • Reaching men as partners in family planning services can also be an important entry point to address respectful relationships and intimate partner violence. 

 

2.  Maternal and child health programmes

  • The negative consequences of violence for pregnant women and their infants, coupled with the evidence of high rates of violence against pregnant and postpartum women in many countries, make a strong argument for routine screening for intimate partner violence in maternal and child health services. As many as 1 in 4 women experience physical or sexual violence during pregnancy (Heise et al., 1999). 
  • An evaluation of interventions in prenatal clinics in the US to identify and address abuse found that two groups of pregnant women who received either: (i) a referral card and a brochure about abuse; or (ii) counselling and mentoring during their pregnancy, reported lower levels of physical violence after several months. Because of the similar outcomes for both groups, the evaluators concluded that the screening assessment may itself be the most effective intervention to prevent abuse to pregnant women.  The assessment signals that abuse is serious and of concern to the health care provider, and that help is available if needed (Mcfarlane et al., 2000, cited in Haider, 2009). 
  • Pregnancy and the postpartum period offer a “window of opportunity” to identify and assist survivors because health professionals may see clients on several occasions (Macy et al., 2007). Where trained providers are in place, screening can be implemented by using a simple abuse assessment protocol during prenatal care. 
  • Adolescent girls in particular should be considered high risk for violence and screened appropriately (Reichenheim et al., 2008), as well as women and girls who have experienced miscarriages (de Bruyn, 2003).
  • In settings where midwives or traditional birth attendants provide care for women and girls at the community level, there should be training for early detection of abuse and appropriate referrals for assistance.  

Example: Midwives Break Cultural Taboos Surrounding Rape (Mauritania)

Midwives and imams have helped break cultural taboos about the discussion of rape in Mauritania. Prior to 2003, survivors of rape in Mauritania were thrown in jail while the perpetrators went free. Correcting that gross injustice—and getting society to recognize the problem of rape at all—began with the grass-roots efforts of four Mauritanian midwives, who could no longer ignore the stories they were hearing from their clients. With UNFPA support, the first statistics on sexual violence in Mauritania were collected, and a centre was established to respond to the multiple needs of survivors. Breaking the taboos surrounding the discussion of rape was the first step in addressing the problem. Local imams lent their support to the effort, convincing government officials, judges, the police and members of the community that protecting women and easing the suffering of those who are most vulnerable was a religious obligation.

See a short video on this initiative.  

 

Source: excerpted from UNFPA, 2006. Ending Violence Against Women: Programming for Prevention, Protection and Care, p. 72.

 

Example:  Reducing the Social Causes of Maternal Morbidity and Mortality in Chiapas, Mexico

The Family Violence Prevention Fund and Asesoria, Capacitacion y Asistencia en Salud partnered to develop a coordinated health response to abuse during pregnancy in order to reduce morbidity and mortality of both pregnant women and their babies.  Strategies to achieve this goal include:  training regional health care providers and traditional birth attendants to identify and assist women abused during pregnancy; producing a culturally and linguistically accessible training module and video for indigenous women in Mexico; facilitating linkages between formal health care facilities and local lay health care providers; producing and implementing a protocol for screening and responding to abuse during pregnancy; and identifying and evaluation promising practices that could be replicated in other regions beyond Mexico.

For additional information, see the website

Source: excerpted from: Guedes, A., 2004. “Addressing Gender-Based Violence from the Reproductive Health/HIV Sector: A Literature Review and Analysis.”  Washington, DC: USAID Interagency Gender Working Group, pg 43.

 

3.  Routine gynecological check-ups

  • Women who have experienced physical or sexual violence from their intimate partners are in general three times more likely to have a symptom of gynecological morbidity (Campbell, 2002). Other traditional practices, such as FGM/C, vaginal drying, etc. may also cause women chronic pain from gynecological conditions.
  • Since women are often ashamed to disclose violence, especially with an intimate partner, training should alert providers to probe for possible sexual violence when women have repeated gynecological issues such as reproductive tract infections.   Pelvic exams also give the opportunity to note vaginal or anal lesions, or bruises in the genital area, and should trigger sensitive, supportive questioning to help women get support to address the sexual violence and to leave the abusive situation if she so decides.
  • In countries where abortion is legal, abortion providers should always screen for violence against women and girls.  Some women who have undergone rape will present this as the reason for wanting the abortion, especially in countries where abortion is restricted and rape is one of the legal causes.  In other cases where women do not mention violence, screening for violence against women and girls is still appropriate, since some women may seek services because they do not want more children with a violent partner, or because they have experienced rape, sexual abuse or incest are too ashamed to disclose.    

4. Safe Abortion services

  • In countries where abortion is legal, abortion providers should always screen for violence against women and girls.  Some women who have undergone rape will present this as the reason for wanting the abortion, especially in countries where abortion is restricted and rape is one of the legal causes.  In other cases where women do not mention violence, screening for violence against women and girls is still appropriate, since some women may seek services because they do not want more children with a violent partner, or because they have experienced rape, sexual abuse or incest are too ashamed to disclose.  

 

Illustrative Tools:

Abuse during Pregnancy:  A Protocol for Prevention and Intervention, 2nd Edition (McFarlane, J., Parker, B. and Cross B., 2002). This module is targeted to nurses and nurse midwives to enable them to prevent abuse, interrupt existing abuse and protect the safety and well-being of pregnant women. Available in English.

Tools for Improving Maternal Health and Safety (Family Violence Prevention Fund). The website includes access to information on the dynamics of domestic violence; implementing a domestic violence programme in health care settings; training resources; educational materials and links to other resources in English and Spanish.

Violence and Maternal Health in Multicultural Contexts (Asesoría, Capacitación y Asistencia en Salud; Centro de Investigaciones y Estudios Superiores en Antropología Social, Mexico). See the power point and access the tools and audio recordings on the Family Violence Prevention Fund's Website.

 

Additional Resources:

“Basta!” (International Planned Parenthood Federation/Western Hemisphere Region).  Videos and tools on gender-based violence for health care providers primarily in sexual and reproductive health services. Available in English and Spanish.  

Addressing Gender-based Violence from the Reproductive Health/HIV Sector: A Literature Review and Analysis (Guedes, A., 2004). Washington, DC: USAID, Bureau for Global Health. Available in English.

Reproductive Health Services and Intimate Partner Violence: Shaping a Pragmatic Response In Sub-Saharan Africa (Watts, C., and Mayhew, S., 2004). International Family Planning Perspectives 30, no. 4: 207-13. Available in English, French and Spanish.

Delivering Post-rape Care Services: Kenya’s Experience in Developing Integrated Services (Kilonzo N, Theobald SJ, Nyamato E, Ajema C, Muchela H, Kibaru J, Rogena E, Taegtmeyer M., 2009). Bulletin World Health Organization 87, no. 7: 555-9. Available in English.

The Refentse Model for Post-Rape Care: Strengthening Sexual Assault Care and HIV Post-Exposure Prophylaxis in a District Hospital in Rural South Africa (Kim, J.C., Askew, I., Muvhango, L., Dwane, N., Abramsky, T., Jan, S., Ntlemo, E., Chege, J. and Watts, C./Population Council, 2009). Available in English.

Violence, Pregnancy and Abortion - Issues of Women's Rights and Public Health (De Bruyn/Ipas, M. 2003). IPAS. Available in English.

Inter-agency Field Manual on Reproductive Health in Humanitarian Settings (Interagency Working Group, 2010). Available in English and Spanish.

An Evaluation of Interventions to Decrease Intimate Partner Violence to Pregnant Women (McFarlane, J., Soeken, K. and Wiist, W., 2000). Public Health Nursing, Vol. 17, No. 6, 443-451. Available in English.

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