Introduction
Violence Against Women (VAW) and intimate partner violence (IPV) describe the violence inflicted by spouse, intimate partner (IPV), or others (domestic violence) against women and affect millions of women regardless of age, economic status, race, religion, ethnicity, or education and background. Consequences of IPV are acute visible injuries to body parts, genitalia, abdomen, chronic headaches, depression, chronic pelvic pain, and irritable bowel syndrome, which are clinical manifestations of internalized stress. Violence against women has been associated with poor pregnancy outcome, anemia, still birth, abortion, abruption, fetal injury, preterm delivery, and low birth weight.
Case Report
A 25-year-old woman, G6P3L2A3, with 3 months amenorrhea presented with severe hemorrhage to the emergency admission room at a tertiary hospital, Hyderabad, Osmania Medical College.
She was married for 12 years and had two children , both by cesarean section. 1st delivery was full term cesarean section, female child, 10 years old for cepahalo pelvic disproportion and 2nd delivery was by emergency cesarean section, female child, 8 years old. 3rd, 4rth, 5th and 6th ( present pregnancy) were induced abortions between 2 and 3 months amenorrhea by over-thecounter MTP pills administered by husband. She needed check curettage twice at a private hospital for incomplete abortions. She completed graduation and was employed irregularly. Husband had studied till 12th standard , alcoholic,and had irregular employment.
General condition She was pale with tachycardia, tachypnea, and hypotension. Gynecological examination revealed 12- to 14-week-size uterus, cervical os open with products of conception. Her urine pregnancy test was positive. She was revived immediately with IV fluids and required to be transfused with four units of blood. Hemoglobin was 5g before transfusion. Rest of the investigations were within normal limits. Her parents reported after few hours, and with due consent, evacuation of POC was done under antibiotic coverage and analgesia.
As she was accompanied by only her minor daughters in a serious condition, the reasons for the same were elicited in history. Her case history was documented as a pilot study for a planned observational study in future on violence against women. Informed consent was taken, and the intimate partner violence proforma for assessment of abuse was completed (“Appendix”). The woman gave history of severe physical violence, starvation, not allowed to use family planning method. She also faced emotional abuse regarding giving birth to girl children, reproductive coercion by forcing abortions, and leaving her to bleed.
Her mother though supportive was helpless, whereas father supported the son in law as he had two more daughters to marry and forced her to continue with the abusive partner. Though she was reasonably educated and worked in the past, she was subjected to severe physical violence and forced to leave the job. The daughters were also neglected.
The next decision was to provide her family planning option, for which the parents initially refused to give consent or support. Eventually, she underwent tubectomy with mother giving consent, and she was later directed to Bharosa one stop crisis center for violence to receive help and rehabilitation.
Discussion
A significant number of women experienced violence during their pregnancy period. Prevalence data of violence during pregnancy revealed that 1–9% in India experienced violence [1]. The preference for male child and the belief that woman is solely responsible for the birth of male child are few reasons for violence during pregnancy. On the other hand, violence itself (sexual violence and reproductive) can cause unwanted pregnancies, forceful illegal abortions exposing the woman to grave risk of hemorrhage, infection, and death [2] Women who face violence also are not in a position to negotiate the use of condom/barrier or contraception leading to STIs, HIV and long-term effects on reproductive health [2]. In this case, though it appeared to be an incomplete abortion and categorized as maternal near miss due to abortion, the real cause is intimate partner violence (IPV).
Many cases of maternal near miss and mortality have underlying abuse as a root cause acting either directly by physical violence leading to bleeding, injuries or indirectly by neglect, malnutrition, missed antenatal care, delayed seeking of care, eclampsia, abortions, STIs, etc. It is imperative to have a universal screening protocol for violence with proper training and protocol. Government of India also has focused on violence against women (VAW) through NFHS 4 survey, high lighting its prevalence across the country. FOGSI is also coming up with Campaign DHEERA Stop Violence against women, to sensitize young people and obstetricians and gynecologists.
Conclusion
As obstetricians and primary care givers to women, we have a big role to play to address violence against women. Universal screening with any one of the abuse assessment screens, provision of pespectful abortion and maternity care and linking up with one stop crisis centers/Sakhi centers go a long way. Without addressing VAW, all the other important SDG goals may remain difficult to achieve.
Dr.S.Shantha Kumari
Dr S.Shantha Kumari is President FOGSI 2021-2022 ,FIGO Treasurer (first woman and Indian to be elected to the Prestigious post) 2021. She is presently Senior Consultant OBGYN and Laparoscopic Surgeon, Yashoda Hospitals, Hyderabad. She received FRCOG (Honoris Causa) UK and FRCPI of Ireland, recipient of Pride of FOGSI Award, 2019, FOGSI STAR award 2017 MOGS Mr N. A . Pandit and Mrs Shailaja Pandit award 2020, and many more. She initiated DHEERA a sociomedical Campaign to eliminate Violence against Women (VAW) 2015. She served as FIGO member for Committee for human rights, Refugees and Violence against Women 2018-2021, Chairperson FOGSI -ICOG 2018, Secretary ICOG 2015-2017 and as National Corresponding Editor for JOGI 2011-2013. She was Vice President FOGSI 2013, IAGE Managing committee member 2012–2018.
Appendix: Questionnaire for Abuse
Did you face violence before during or after pregnancy—YES/NO
What type of violence
- Physical
- slapping,
- kicking,
- beating,
- pushing
- Verbal/Emotional/Psychological
- scolding,
- humiliating,
- belittling
- calling names,
- denying freedom to speak/work/express
- Reproductive coercion
- denying use of condom,
- spacing,
- forcing abortion
- Sexual violence
- forceful sexual activity without consent/rape
Declarations
Conflict of interest
The authors declare that there are no conflicts of interests.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Footnotes
Dr.S. Shantha Kumari is a Senior Consultant Obstetrician & Gynaecologist Laparoscopic Surgeon- Yashoda Hospitals, Hyderabad, India. Dr. Kiranmai Devineni is a Associate Professor, Obstetrics and Gynaecology Osmania Medical College, Hyderabad, Telangana, India. Dr.Nagamani Sodumu is a Professor and HOD, Obstetrics and Gynaecology Modern Government Maternity Hospital, Petlaburz Osmania Medical College, Hyderabad, Telangana, India.
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References
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