Dr Rachel Jewkes is a Senior Specialist with the South African Medical Research Council based in Pretoria. Dr Jewkes is also an advisor and Steering Group member of the World Health Organizations' Multi-Country Study on Domestic Violence Against Women

Introduction:

One of the most significant achievements of the last decade of the millennium has been the recognition given by the United Nations and a growing number of governments, including that of South Africa, that violence against women is a human rights issue. In 1993 the United National General Assembly adopted a declaration which for the first time offers an official UN definition of gender-based abuse. According to Article 1 of the declaration, violence against women includes:

"Any act of gender-based violence that results in or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life."

Article 2 of the Declaration states that the definition should be understood to encompass, but not be limited to, physical, sexual and psychological violence occurring in the family and in the community, including battering, sexual abuse of female children, dowry-related violence, marital rape, female genital mutilation (FGM) and other traditional practices harmful to women, non-spousal violence, violence related to exploitation, sexual harassment, and intimidation at work, in educational institutions, and elsewhere, trafficking in women, forced prostitution, and violence perpetrated or condoned by the state.

Whilst this is a very significant development, in most countries there has been very little policy attention given to addressing violence against women as a public health issue and even less to tackling its underlying causes. Violence against women impacts on sexual and reproductive health in multiple ways and the eradication of this violence must become an integral part of efforts to promote the sexual and reproductive health of women worldwide.

Gender violence throughout the sexual and reproductive life cycle

Magnitude of Gender-Based violence:

Understanding of the magnitude of the problem of gender-based violence and its causative factors and mechanisms is greatly hampered by the lack of well-designed population-based studies in many countries. Although there is research in progress in many countries, coordinated through the World Health Organization (WHO), most of the completed in-depth research has been from North America.

Data on the prevalence of rape is even more difficult to find. The data from South Africa collected from representative community-based studies gives some idea of the magnitude of the problem in this country. In the 1998 Demographic & Health Survey, 4.4% of all women interviewed aged 15-49 reported having ever been raped. This figure was actually lower than the researchers had expected to find given that studies of teenage sexuality have found almost one third of teenage girls reporting forced sexual initiation (e.g. Buga et al 1996, Richter 1996).

Gender-based violence usually continues during pregnancy and may take different forms and have different consequences. In recent research from South Africa, women were asked about whether they had experienced different types of abuse during pregnancy. The results are presented below. These findings were very similar to those of research undertaken in Zimbabwe in 1996.

Abuse during pregnancy in South Africa:

(Source: Jewkes et al 1999)

The Impact of Gender-Based Violence on Reproductive Health:

Gender-based and sexual violence has multiple impacts on the reproductive health of women and girls.

Teenage pregnancy

Teenage pregnancy is regarded as a major problem in many countries. In South Africa, for example, 35% of women under 20 years have been pregnant or have a child (Department of Health, 1999). Since marriage is late, most of these young women are unmarried and still at school. Teenage pregnancy reduces the likelihood of the mother completing schooling, reduces prospects for subsequent employment and earnings, compromises the financial position of her family's household (maintenance from the father is rarely forthcoming), and negatively impacts on the child, who is born into relatively greater poverty.

In South Africa, research into teenage pregnancy has shown that after adjusting for socio-economic and other factors, forced sexual initiation was found to increase the risk of teenage pregnancy by14 times (Vundule et al, forthcoming). Forced sexual initiation was found to have a major impact on the likelihood of pregnancy occurring years later. In the USA, women raped in childhood were three times as likely to have teenage pregnancies (Zierler et al 1991).

High risk sexual practices

High risk sexual practices - including having sex for material reward, having multiple partners and casual partners - are associated with a greater likelihood of unwanted pregnancy, STDs and HIV infection. Research in several countries has shown that child sexual abuse is associated with increased risk of unsafe sexual practices. Handwerker (1993) showed that in Barbados, the most important determinant of high risk sexual activity amongst adolescents was child sexual abuse. In the USA, women raped in childhood were four times as likely to go into prostitution and twice as likely to have casual sexual partners (Zierler et al 1991).

HIV/STDS

HIV poses a major threat to the lives of a very substantial number of Commonwealth citizens. In South Africa, at the end of 1998, three million were estimated to be infected with the virus. HIV transmission again is facilitated in multiple ways by gender-based violence. The most obvious form is during rape. There is a lack of research on the likelihood of HIV infection after rape, but there is some data on transmission of STDs. For example, in a study organized by a women's NGO in Thailand, 10 percent of raped women were found to have acquired STDs (Archavanitkni & Pramualvatana 1990).

Violence or the fear of violence has been shown to reduce women's ability to negotiate condom use (Heise et al 1993). In many cultures suggesting condom use is tantamount to implying or admitting infidelity, as condoms are associated with prostitution, promiscuity and disease. A suggestion of condom use can be perceived as an implicit challenge to a male's right to have many women.

At the same time many women know that their partners have other sexual partners. In South Africa, for example, a common form of emotional abuse of a spouse involves boasting about or bringing home other women to have sex with them in the marital bed. Recent research found that 10 percent of women in one province reported that their spouse had done this in the previous year (Jewkes et al 1999).

In many cultures women who are married or living with a man perceive that they cannot refuse his requests for sex. This undermines their ability to use this as a sanction to enforce condom use, even if their partner has a visible STD. In South African research, for example, 57% of women living in the Eastern Cape believed that they could not refuse sex with their partner (Jewkes et al 1999). In the light of all this it is perhaps not surprising that this study also found that HIV prevention was discussed significantly less often in relationships with physical violence.

A further source of vulnerability to HIV infection stems from sexual harassment and exploitation of schoolgirls by older men, and particularly school teachers. This renders these girls extremely vulnerable to HIV and explains why in a country like South Africa the HIV epidemic in young women starts and peaks some five years earlier than in young men.

Pregnancy Outcomes

Although there is controversy about whether women who are pregnant experience more abuse than non-pregnant women, gender-based violence has been associated with poor perinatal outcomes. Partner battering has been identified in several countries as an appreciable cause of maternal mortality. The most recent reports of confidential enquiries into maternal deaths in South Africa and in the UK have both identified gender-based violence as causes of death (Department of Health 1998, Department of Health,1999b).

Domestic violence has been associated with foetal distress and foetal death at all stages (Dye et al 1995). The 1998 South Africa Demographic & Health Survey data shows that women who had been physically abused by an intimate partner in the past were twice as likely (12.1 percent against 6.3 percent) to have experienced pregnancy loss as non-abused women. This difference was statistically significant. The same study also showed that stillbirths were higher for women who had been abused by an intimate partner in the past. These women reported 15 stillbirths per thousand women, compared with 10 per thousand amongst women who had never been abused.

The table on abuse on pregnancy presented earlier shows that abusive spouses often prevent women from using antenatal care. This finding has also been confirmed by the 1998 South Africa Demographic & Health Survey data which shows that women who had been physically abused by an intimate partner in the past were less likely to have had antenatal care than non-abused women (18 percent against 21 percent).

Conclusions:

Improving women's sexual and reproductive health has been a key objective of all governments after the International Conference on Population and Development (ICPD) in Cairo 1994. Gender-based violence impacts on all the most serious sexual and reproductive health problems facing women in the Commonwealth. If these health problems are to be effectively addressed and, in particular, the tide of the HIV epidemic reversed, every government must commit itself to effectively combatting gender-based violence.

Medical Research Council
Private Bag X385, Pretoria 0001, South Africa
Tel: 021 339 8525 Fax: 021 339 8582 Email: Rjewkes@mrc.ac.za

References:

Archavanitkui K, Pramualratana A (1990) Factors affecting women's health in Thailand. Paper presented at the Workshop on Women's Health in Southeast Asia, population Council, Jakata, October 29-31.

Bergman B, Brismar B, Nordin C (1992) "Utilisation of Medical Care by Abused Women". BMJ 305. 27-28.

Buga GAB, Amoko DHA, Ncayiyana D. (1996) "Sexual Behaviour, Contraceptive Practices and Reproductive Health Among School Adolescents in Rural Transkei". South African Medical Journal 86,523-527.

Department of Health (1999) South Africa Demographic and Health Survey. Preliminary report. Department of Health, Pretoria.

Departments of Health (1999b) Saving Mothers. Report on Confidential Enquiries into Maternal Deaths in South Africa 1998. Department of Health, Pretoria.

Department of Health, Welsh Office, Scottish Office Department of Health, Department of Health and Social Services NI (1998) Why Mothers Die. Report of Confidential Enquiries into Maternal Deaths in the United Kingdom 1994-1996. TSO, London.

Dye TD, Tollivert NJ, Lee RV, Kenney CJ (1995) "Violence, Pregnancy and Birth Outcome in Appalacia". Paediatric and Perinatal Epidemiology, 9, 35-47.

Handwerker P (1993) Power, Gender Violence and High Risk Sexual Behaviour: AIDS/STD Risk Factors Need to be Defined More Broadly. Humboldt State University, Department of Anthropology.

Heise L, Pitanguay J, Germain A (1993) Violence Against Women. The Hidden Health Burden. World Bank Discussion Paper 255.

Jewkes R, Penn-Kekana L, Levin L, Ratsaka M, Schrieber M (1999) He must give me Money, He mustn't beat me: Violence against women in three South African Provinces. Medical Research Council Technical Report, Pretoria.

McFarlane J, Parker B, Soeken K (1996) "Abuse During Pregnancy: Associations with Maternal Health and Infant Birth Weight". Nursing Research 45, 37-42.

Vundule C, Maforah NF, Jewkes R, Jordaan E (in press) "Risk Factors for Teenage Pregnancy Amongst African Adolescents in Metropolitan Cape Town: A Case Control Study". South African Medical Journal