IJG-08585; No of Pages 2 International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
SPECIAL EDITORIAL
Violence against women must concern obstetrician–gynecologists
Rachel Jewkes
Professor Rachel Jewkes is a medical doctor and physical health specialist, and the Director of the South African Medical Research Council’s Gender and Health Research Unit. She is a former Vice-President of the Medical Research Council, and is leading the DFID-supported What Works to Prevent Violence Global Programme, which is funding research and innovation in prevention of gender-based violence in 14 countries in Asia, the Middle East, and Africa. She is also Secretary of the Sexual Violence Research Initiative (SVRI). Violence against women (VAW) occurs in every country, and onethird of women worldwide have experienced partner violence [1]. Risk of recent exposure to intimate partner violence and rape—the two most widespread forms of VAW—varies considerably, and in many populations, more than one in five women have experienced violence in the past year [2,3]. Female genital mutilation and child
marriage are also very highly prevalent in some parts of Africa and Asia, and are important forms of VAW. Both lifetime exposure to violence and controlling behaviors from a spouse or male partner, and current violence are risk factors for a range of women’s health problems [4,5]. Women exposed to violence are more likely to have unwanted pregnancies (and also induced abortion, commonly in unsafe conditions) and sexually transmitted infections (including HIV) [5]. In this issue of IJGO, Zakar et al. [6] show that emotional and physical intimate partner violence are associated with unintended pregnancy and pregnancy loss in Pakistan. Conversely, Iliyasu et al. [7] and Stellar et al. [8] highlight the problem of intimate partner violence among subfertile and infertile women in low- and middle-income countries. Women exposed to violence also have poorer obstetric outcomes, with a higher risk of low birth weight due to the stress of living in an abusive relationship, and of premature birth, which can follow acts of violence [5]. Mental distress—depression, anxiety, substance misuse, and suicidal behavior and ideation—is also very strongly associated with experience of violence [5]. The critical question is: how should the health system respond to this important risk factor? Many challenges have been identified, including cultural viewpoints and poor awareness as outlined by Viswanathan et al. in this issue [9]. For all forms of VAW, the global consensus is that health professionals should be able and willing to identify patients experiencing violence in an appropriate and sensitive manner, and to provide first-line supportive care that includes empathetic listening, immediate psychosocial support, meeting of immediate healthcare needs, and referral to other services [10]. To achieve this first step, the issues of VAW and how to respond need to be taught within medical, nursing, public health, and other relevant curricula, especially those for specialist training in obstetrics–gynecology and midwifery. Obstetrician–gynecologists can often be the first person to whom a woman might disclose rape or a history of sexual abuse in childhood. Providing comprehensive care in this context is critical, and the nature of this care varies depending on the time since the sexual assault, especially if recent or much longer in the past. The International Federation of Gynecology and Obstetrics has issued guidelines for the provision of comprehensive post-rape care [11]. One of the key challenges is that ongoing violence is not amenable to a quick fix and cannot be ended by a simple intervention within a health setting. A range of different interventions to help women to reduce their violence exposure have been evaluated, with very mixed results [12,13]. The evidence of effective interventions in healthcare services remains scarce, especially among resource-poor settings [10], where women often have highly constrained choices for economic, social, and emotional reasons. Although there is general consensus about how to ask about VAW and enable victims to be identified, there is a need for
http://dx.doi.org/10.1016/j.ijgo.2016.01.003 0020-7292/© 2016 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Jewkes R, Violence against women must concern obstetrician–gynecologists, Int J Gynecol Obstet (2016), http:// dx.doi.org/10.1016/j.ijgo.2016.01.003
2
Special editorial
further research on interventions and response models that would be useful for low- and middle-income countries. There is also a need for more research on the health impact of violence, because it will help to build a case that countries cannot afford not to invest in prevention of VAW. VAW is preventable, even if the role of the health sector in prevention remains unclear. There have been rigorously conducted clinical trials in a range of global settings that have shown effect in this regard. Promising interventions have included the SHARE intervention in Uganda, which combined community-level mobilization to change attitudes, social norms, and behaviors related to VAW, and an intervention to promote safe disclosure of HIV and risk reduction among women seeking HIV counselling and testing services. This reduced both women's exposure to violence and HIV acquisition [14]. Other community-mobilization interventions have also shown promise [3]. Interventions that combine women’s economic empowerment and gender awareness training have shown an effect [15], as have interventions with men and boys to build more respectful and equitable relationships. High schools have also been shown to be an effective delivery platform for interventions to prevent violence, both during class and after school [16]. There is a need to expand the evidence around violence prevention. An important initiative funded by the UK Department for International Development—the What Works To Prevent Violence Against Women and Girls Programme—is underway, with research funded in Africa, the Middle East, and Asia (http://www.whatworks.co.za). It will generate knowledge about violence prevention settings, including fragile and conflict settings, and about the economic and social costs. Violence prevention work in the community complements endeavors within healthcare settings, and working together, there are very real possibilities of ending this scourge. References [1] Devries KM, Mak JY, García-Moreno C, Petzold M, Child JC, Falder G, et al. Global health. The global prevalence of intimate partner violence against women. Science 2013;340(6140):1527–8. [2] Sambisa W, Angeles G, Lance PM, Naved RT, Thornton J. Prevalence and correlates of physical spousal violence against women in slum and nonslum areas of urban Bangladesh. J Interpers Violence 2011;26(13):2592–618. [3] Abramsky T, Devries K, Kiss L, Nakuti J, Kyegombe N, Starmann E, et al. Findings from the SASA! Study: a cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda. BMC Med 2014;12:122.
[4] Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet 2010;376(9734):41–8. [5] World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization; 2013. [6] Zakar R, Nasrullah M, Zakar MZ, Ali H. The association of intimate partner violence with unintended pregnancy and pregnancy loss in Pakistan [published online ahead of print December 16, 2015]. Int J Gynecol Obstet. http://dx.doi.org/10. 1016/j.ijgo.2015.09.009. [7] Iliyasu Z, Galadanci HS, Abubakar S, Auwal MS, Odoh C, Salihu HM, et al. Phenotypes of intimate partner violence among women experiencing infertility in Kano, Northwest Nigeria [published online ahead of print December 11, 2015]. Int J Gynecol Obstet. http://dx.doi.org/10.1016/j.ijgo.2015.08.010. [8] Stellar C, Garcia-Moreno C, Temmerman M, van der Poel S. A systematic review and narrative report of the relationship between infertility, subfertility, and intimate partner violence [published online ahead of print December 15, 2015]. Int J Gynecol Obstet. http://dx.doi.org/10.1016/j.ijgo.2015.08.012. [9] Viswanathan N, Carretero L, Afzal O, Rodriguez SI, Shirazian T. Understanding the challenges of addressing intimate partner violence in the Dominican Republic [published online ahead of print November 7, 2015]. Int J Gynecol Obstet. http:// dx.doi.org/10.1016/j.ijgo.2015.07.018. [10] García-Moreno C, Hegarty K, d’Oliveira AF, Koziol-MacLain J, Colombini M, Feder G. The health-systems response to violence against women. Lancet 2015;385(9977): 1567–79. [11] Jina R, Jewkes R, Munjanja SP, Mariscal JD, Dartnall E, Gebrehiwot Y, et al. Report of the FIGO Working Group on Sexual Violence/HIV: Guidelines for the management of female survivors of sexual assault. Int J Gynecol Obstet 2010;109(2):85–92. [12] Jewkes R. Intimate partner violence: the end of routine screening. Lancet 2013; 382(9888):190–1. [13] World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: World Health Organization; 2013. [14] Wagman JA, Gray RH, Campbell JC, Thoma M, Ndyanabo A, Ssekasanvu J, et al. Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort. Lancet Glob Health 2015;3(1):e23–33. [15] Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet 2006;368(9551):1973–83. [16] Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Puren A, et al. Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ 2008;337:a506.
Rachel Jewkes South African Medical Research Council, Pretoria, South Africa E-mail address: [email protected].
Available online xxxx
Please cite this article as: Jewkes R, Violence against women must concern obstetrician–gynecologists, Int J Gynecol Obstet (2016), http:// dx.doi.org/10.1016/j.ijgo.2016.01.003
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
SPECIAL EDITORIAL
Violence against women must concern obstetrician–gynecologists
Rachel Jewkes
Professor Rachel Jewkes is a medical doctor and physical health specialist, and the Director of the South African Medical Research Council’s Gender and Health Research Unit. She is a former Vice-President of the Medical Research Council, and is leading the DFID-supported What Works to Prevent Violence Global Programme, which is funding research and innovation in prevention of gender-based violence in 14 countries in Asia, the Middle East, and Africa. She is also Secretary of the Sexual Violence Research Initiative (SVRI). Violence against women (VAW) occurs in every country, and onethird of women worldwide have experienced partner violence [1]. Risk of recent exposure to intimate partner violence and rape—the two most widespread forms of VAW—varies considerably, and in many populations, more than one in five women have experienced violence in the past year [2,3]. Female genital mutilation and child
marriage are also very highly prevalent in some parts of Africa and Asia, and are important forms of VAW. Both lifetime exposure to violence and controlling behaviors from a spouse or male partner, and current violence are risk factors for a range of women’s health problems [4,5]. Women exposed to violence are more likely to have unwanted pregnancies (and also induced abortion, commonly in unsafe conditions) and sexually transmitted infections (including HIV) [5]. In this issue of IJGO, Zakar et al. [6] show that emotional and physical intimate partner violence are associated with unintended pregnancy and pregnancy loss in Pakistan. Conversely, Iliyasu et al. [7] and Stellar et al. [8] highlight the problem of intimate partner violence among subfertile and infertile women in low- and middle-income countries. Women exposed to violence also have poorer obstetric outcomes, with a higher risk of low birth weight due to the stress of living in an abusive relationship, and of premature birth, which can follow acts of violence [5]. Mental distress—depression, anxiety, substance misuse, and suicidal behavior and ideation—is also very strongly associated with experience of violence [5]. The critical question is: how should the health system respond to this important risk factor? Many challenges have been identified, including cultural viewpoints and poor awareness as outlined by Viswanathan et al. in this issue [9]. For all forms of VAW, the global consensus is that health professionals should be able and willing to identify patients experiencing violence in an appropriate and sensitive manner, and to provide first-line supportive care that includes empathetic listening, immediate psychosocial support, meeting of immediate healthcare needs, and referral to other services [10]. To achieve this first step, the issues of VAW and how to respond need to be taught within medical, nursing, public health, and other relevant curricula, especially those for specialist training in obstetrics–gynecology and midwifery. Obstetrician–gynecologists can often be the first person to whom a woman might disclose rape or a history of sexual abuse in childhood. Providing comprehensive care in this context is critical, and the nature of this care varies depending on the time since the sexual assault, especially if recent or much longer in the past. The International Federation of Gynecology and Obstetrics has issued guidelines for the provision of comprehensive post-rape care [11]. One of the key challenges is that ongoing violence is not amenable to a quick fix and cannot be ended by a simple intervention within a health setting. A range of different interventions to help women to reduce their violence exposure have been evaluated, with very mixed results [12,13]. The evidence of effective interventions in healthcare services remains scarce, especially among resource-poor settings [10], where women often have highly constrained choices for economic, social, and emotional reasons. Although there is general consensus about how to ask about VAW and enable victims to be identified, there is a need for
http://dx.doi.org/10.1016/j.ijgo.2016.01.003 0020-7292/© 2016 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Jewkes R, Violence against women must concern obstetrician–gynecologists, Int J Gynecol Obstet (2016), http:// dx.doi.org/10.1016/j.ijgo.2016.01.003
2
Special editorial
further research on interventions and response models that would be useful for low- and middle-income countries. There is also a need for more research on the health impact of violence, because it will help to build a case that countries cannot afford not to invest in prevention of VAW. VAW is preventable, even if the role of the health sector in prevention remains unclear. There have been rigorously conducted clinical trials in a range of global settings that have shown effect in this regard. Promising interventions have included the SHARE intervention in Uganda, which combined community-level mobilization to change attitudes, social norms, and behaviors related to VAW, and an intervention to promote safe disclosure of HIV and risk reduction among women seeking HIV counselling and testing services. This reduced both women's exposure to violence and HIV acquisition [14]. Other community-mobilization interventions have also shown promise [3]. Interventions that combine women’s economic empowerment and gender awareness training have shown an effect [15], as have interventions with men and boys to build more respectful and equitable relationships. High schools have also been shown to be an effective delivery platform for interventions to prevent violence, both during class and after school [16]. There is a need to expand the evidence around violence prevention. An important initiative funded by the UK Department for International Development—the What Works To Prevent Violence Against Women and Girls Programme—is underway, with research funded in Africa, the Middle East, and Asia (http://www.whatworks.co.za). It will generate knowledge about violence prevention settings, including fragile and conflict settings, and about the economic and social costs. Violence prevention work in the community complements endeavors within healthcare settings, and working together, there are very real possibilities of ending this scourge. References [1] Devries KM, Mak JY, García-Moreno C, Petzold M, Child JC, Falder G, et al. Global health. The global prevalence of intimate partner violence against women. Science 2013;340(6140):1527–8. [2] Sambisa W, Angeles G, Lance PM, Naved RT, Thornton J. Prevalence and correlates of physical spousal violence against women in slum and nonslum areas of urban Bangladesh. J Interpers Violence 2011;26(13):2592–618. [3] Abramsky T, Devries K, Kiss L, Nakuti J, Kyegombe N, Starmann E, et al. Findings from the SASA! Study: a cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda. BMC Med 2014;12:122.
[4] Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet 2010;376(9734):41–8. [5] World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization; 2013. [6] Zakar R, Nasrullah M, Zakar MZ, Ali H. The association of intimate partner violence with unintended pregnancy and pregnancy loss in Pakistan [published online ahead of print December 16, 2015]. Int J Gynecol Obstet. http://dx.doi.org/10. 1016/j.ijgo.2015.09.009. [7] Iliyasu Z, Galadanci HS, Abubakar S, Auwal MS, Odoh C, Salihu HM, et al. Phenotypes of intimate partner violence among women experiencing infertility in Kano, Northwest Nigeria [published online ahead of print December 11, 2015]. Int J Gynecol Obstet. http://dx.doi.org/10.1016/j.ijgo.2015.08.010. [8] Stellar C, Garcia-Moreno C, Temmerman M, van der Poel S. A systematic review and narrative report of the relationship between infertility, subfertility, and intimate partner violence [published online ahead of print December 15, 2015]. Int J Gynecol Obstet. http://dx.doi.org/10.1016/j.ijgo.2015.08.012. [9] Viswanathan N, Carretero L, Afzal O, Rodriguez SI, Shirazian T. Understanding the challenges of addressing intimate partner violence in the Dominican Republic [published online ahead of print November 7, 2015]. Int J Gynecol Obstet. http:// dx.doi.org/10.1016/j.ijgo.2015.07.018. [10] García-Moreno C, Hegarty K, d’Oliveira AF, Koziol-MacLain J, Colombini M, Feder G. The health-systems response to violence against women. Lancet 2015;385(9977): 1567–79. [11] Jina R, Jewkes R, Munjanja SP, Mariscal JD, Dartnall E, Gebrehiwot Y, et al. Report of the FIGO Working Group on Sexual Violence/HIV: Guidelines for the management of female survivors of sexual assault. Int J Gynecol Obstet 2010;109(2):85–92. [12] Jewkes R. Intimate partner violence: the end of routine screening. Lancet 2013; 382(9888):190–1. [13] World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: World Health Organization; 2013. [14] Wagman JA, Gray RH, Campbell JC, Thoma M, Ndyanabo A, Ssekasanvu J, et al. Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort. Lancet Glob Health 2015;3(1):e23–33. [15] Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet 2006;368(9551):1973–83. [16] Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Puren A, et al. Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ 2008;337:a506.
Rachel Jewkes South African Medical Research Council, Pretoria, South Africa E-mail address: [email protected].
Available online xxxx
Please cite this article as: Jewkes R, Violence against women must concern obstetrician–gynecologists, Int J Gynecol Obstet (2016), http:// dx.doi.org/10.1016/j.ijgo.2016.01.003
