Published Date: November 22, 2005

Violence Against Pregnant Women: A Global Health Crisis

Mary Ellsberg, PhD
Senior Advisor for Gender Violence and Human Rights
PATH

I used to treat women with muscle spasms all the time, and I never asked them any questions. Then I started to realize that many of these cases were due to violence.

Women are waiting for someone to knock on their door; some of them have been waiting for many years... They are grateful for the opportunity to unload their burden.


The words of these Central American health providers illustrate a profound policy shift that has occurred in recent years within the international health community with regard to violence against women. Only 10 years ago, the health needs of abused women were virtually ignored, outside of a few industrialized countries. Now, violence against women is recognized globally as a grave public health concern as well as a human rights issue. In 1996, the World Health Assembly declared violence to be a public health priority, and followed this up in 2002 with the publication of the World Report on Violence and Health, with indepth discussions of intimate partner and sexual violence. This shift is largely due to the tireless efforts of women's rights activists, who lobbied to place violence against women on the global agenda, most notably through the international conferences on human rights (Vienna, 1992), population and development (Cairo, 1993) and the Fourth World Conference on Women (Beijing, 1995).

At the same time, a body of scientific research has demonstrated the truth of what women's rights advocates had been saying for years – that violence against women is an endemic problem that erodes women's physical and mental well-being, interferes with their productive engagement in society, destroys families, and unravels the very fabric of communities.

International studies indicate that between 10-60 percent of women who have ever been married or partnered have experienced at least one incident of physical violence from a current or former intimate partner.² Recent data from a WHO study on domestic violence and women's health found that estimates of partner violence within the last 12 months varied from less than 4 percent in Yokohama, Japan, and Serbia and Montenegro, to 53 percent in rural Ethiopia. Sexual violence within marriage is also common, with approximately 10-30 percent of women reporting having been forced by a partner to have sex against their will at some point.³

International research within the last decade has revealed that sexual abuse of women and girls by non-partners is also much more common than previously thought. Between 10-27 percent of women and girls reported having been sexually abused, either as children or adults. Although intimate partner violence and sexual coercion are the most common types of violence affecting women and girls, in many parts of the world, violence takes on special characteristics according to cultural and historical conditions, such as honor killings, trafficking of women and girls, female genital mutilation, and violence against women in situations of armed conflict.

The devastating impact of sexual and physical violence on women's sexual and reproductive health has also been well documented. Women who have experienced violence are at increased risk for unwanted pregnancy, sexually transmitted diseases, and gynecological disorders. A growing body of research carried out in Tanzania, South Africa and the United States indicates that violence increases women's susceptibility to HIV infection. Sexual coercion is a key factor in explaining women's vulnerability to HIV. Many women are simply not able to make free decisions about the timing and circumstances of sex, much less whether to protect themselves against sexually transmitted infections.

Studies from around the world demonstrate that violence during pregnancy is as common or more than many conditions that are commonly screened for in prenatal care.^4,5 A recent review, including studies from China, Egypt, Ethiopia, Mexico, India, Nicaragua, Pakistan, Saudi Arabia and South Africa,⁵ found that the prevalence of abuse during pregnancy is 3.4 percent to 11.0 percent in industrialized countries outside of North America and between 3.8 percent and 31.7 percent in developing countries.

Violence during pregnancy can have serious health consequences for women and their children.² Documented effects include delayed prenatal care, inadequate weight gain, increased smoking and substance abuse, STIs, vaginal and cervical infections, kidney infections, miscarriages and abortions, premature labor, fetal distress, and bleeding during pregnancy.⁶

Recent research has also focused on the relationship between violence in pregnancy and low birth weight, a leading cause of infant deaths in the developing world. Although research is still emerging, findings from studies performed in the United States, Mexico and Nicaragua suggest that violence during pregnancy contributes to low-birth-weight, pre-term delivery, and to fetal growth retardation, at least in some settings.⁴ According to studies performed in Nicaragua, women who experience physical or sexual violence during pregnancy were four times more likely to deliver a low-birth-weight infant and up to six times more likely to experience an infant death.^7,8 A review of maternal mortality data in Nicaragua found that 10 percent of non-obstetric pregnancyrelated deaths involved physical or sexual violence.

Violence during pregnancy is strongly linked both to a history of violence prior to the pregnancy as well as prevailing cultural norms. Research in the U.S. and elsewhere indicates that the majority of women who are abused in pregnancy were also abused before and after the pregnancy (more than 80 percent in most studies).⁵ A minority of women in all countries studied report that they experienced violence for the first time during a pregnancy.

Researchers have also noted that the levels of violence in pregnancy in different settings appear to be influenced by cultural norms regarding pregnancy. These differences are evident when comparing levels of violence in pregnancy between Ethiopia and Peru, both countries where intimate partner violence is quite high. In rural Ethiopia 49 percent of women have experienced physical violence from a partner during their lifetimes, and in Cusco, Peru the figure is 61 percent of women.^9,10 However, the proportion of women reporting violence during pregnancy is quite different; 8 percent of Ethiopian women reported abuse in pregnancy (15 percent of ever-abused women), compared to 28 percent of women in Peru (44 percent of ever abused women). In a study performed in Central Java, although 10 percent of women reported having been beaten by their husband, less than 1 percent experienced violence in pregnancy.¹¹ These figures suggest that in some societies pregnancy is a time of relative protection from physical violence, whereas in others, abuse in pregnancy is widespread. More research is needed to understand these issues in greater depth.

Violence against women is rooted in women's lack of power in relationships and in society relative to men. In many societies, women are expected to be submissive and sexually available to their husbands at all times, and it is considered both a right and an obligation for men to use violence in order to "correct" or chastise women for perceived transgressions. Violence within the family has been traditionally considered a private matter in which outsiders, including government authorities, should not intervene. For unmarried women, sexual violence is so stigmatizing that most women prefer to suffer in silence than to risk the shame and discrimination that would result from disclosure.

Reproductive health programs, and pre-natal care services in particular, provide a unique window of opportunity to address the needs of abused women, and to safeguard the health of both mothers and infants. However, although recognition of the problem has grown enormously within the health sector and violence is increasingly being included in national health policies and programs, progress has been slow. Although a myriad of successful and innovative pilot programs have been launched, few have been translated successfully into national programs. International donors do not as a rule consider gender or violence within bilateral aid programs supporting HIV prevention, reproductive health, or health reform. This not only ignores an opportunity to strengthen the health sector response to violence, but it also jeopardizes the achievement of other programatic goals.

Recent reviews of interventions in the field of violence against women have concluded that all health sector programs must work closely with other social actors at a national and local level, and particularly in the context of community based networks to improve the government response to violence. Finally, in order to achieve a lasting impact, more efforts are needed to dismantle discriminatory laws and policies against women and to challenge social norms that posit men's right to control female behavior.

For more information on PATH, visit www.path.org

References
¹ Velzeboer M, Ellsberg M, Clavel C, Garcia-Moreno C. Violence against Women: The Health Sector Responds. Washington, DC: Pan American Health Organization, PATH; 2003.

² Heise L, Ellsberg M, Gottemoeller M. Ending Violence Against Women. Baltimore: John's Hopkins University School of Public Health; Population Information Program; 1999. Report No.: Series L No. 11.

³ World Health Organization. WHO Multi-country Study on Women's Health and Domestic Violence Against Women: Report on the First Results. Geneva, Switzerland: WHO; 2005

⁴ Petersen R, Gazmararian JA, Spitz AM, et al. Violence and adverse pregnancy outcomes: A review of the literature and directions for future research. American Journal of Preventive Medicine. 1997;13(5):366-373.

⁵ Campbell J, Garcia-Moreno C, Sharps P. Abuse during pregnancy in industrialized and developing countries. Violence against Women. 2004;10(7):770-789.

⁶ Campbell JC. Health consequences of intimate partner violence. Lancet. 2002; 359 (9314):1331-1336.

⁷ Valladares E, Ellsberg M, Peña R, Högberg U, Persson L-Å. Physical partner abuse during pregnancy: A risk factor for low birth weight in Nicaragua. Obstetrics and Gynecology. 2002;100(4):100-105.

⁸ Åsling-Monemi K, Peña R, Ellsberg M, Persson L. Violence against women increases the risk of infant and child mortality: A case-referent study in Nicaragua. The Bulletin of the World Health Organization. 2003;81:10-18.

⁹ Gossaye Y, Deyessa N, Berhane Y, et al. Women's health and life events study in rural Ethiopia. Ethiopian Journal of Health Development. 2003;17 (Second Special Issue):1-49.

¹⁰ Guezmes A, Palomino N, Ramos M. Violencia Sexual y Física contra las Mujeres en el Perú. Lima: Flora Tristan, Organización Munidial de la Salud, Universidad Peruana Cayetano Heredia; 2002.

¹¹ Hakimi M, Nur Hayati E, Ellsberg M, Winkvist A. Silence for the Sake of Harmony: Domestic Violence and Health in Central Java, Indonesia. Yogyakarta, Indonesia: Gadjah Mada University, PATH, Rifka Annisa, Umeå Univeristy; 2002.