Background

Violence against women is prevalent worldwide and is most commonly inflicted by men. Such violence takes many forms in different settings, sometimes legally sanctioned by the state and/or morally sanctioned by the society within which it occurs. However, while women can be at risk in many settings, the most common form of violence against women is domestic violence or abuse inflicted by the woman’s partner or ex-partner, and the violence usually takes place in the home.

While the term ‘domestic violence’ could imply violence or abuse from either partner in a heterosexual or homosexual relationship, a United Nations report in 1995 recognized that the most common manifestation is violence against women by male partners (United Nations 1995). In the 1992 British Crime Survey (Mayhew et al 1993), domestic violence constituted the single largest category of assaults, with 80% directed against women. In the USA, it is estimated that 95% of battered partners are women (Jones 1997). The United Nations report highlighted the range of types of physical abuse suffered worldwide by women at the hands of their partners, including battering, marital rape, dowry violence, domestic murder, forced pregnancy, abortion, sterilization and forced prostitution. During pregnancy, violence may also cause miscarriage or fetal injury and/or death. Women also experience non-physical abuse in the form of psychological, emotional and economic abuse.

Domestic violence or abuse is difficult to define but a definition such as ‘the psychological, emotional and economic as well as physical and sexual abuse of women by male partners or ex partners’ (Scottish Needs Assessment Programme 1997) indicates the range of ways and circumstances in which women can be abused by their partners. Thus, while society’s perception is that the greatest risk of violence comes from strangers outside the home, statistics confirm that this is not the case for women. Nevertheless, in addition to beating of a wife by her husband, violence against women includes other types of abuse such as abortion of female fetuses, female genital mutilation, forced prostitution by non-partners, rape (including rape and sexual violence as a war strategy) and murder. Women are also at risk of violence or abuse from any relationship or interaction with men in which sex is a factor; thus, while forced prostitution by a partner is itself a form of partner violence, women working as prostitutes, whether for a partner, another man or independently, are also at risk of violence from their clients. However, it is important to recognize that prostitution encompasses a wide spectrum of circumstances; while violence may occur as part of the practice of prostitution, it does not follow that all prostitution constitutes violence against women.

Violence against women is important to those providing reproductive health care. Women experiencing or at risk of violence are particularly vulnerable during pregnancy. Domestic violence often starts or escalates during pregnancy, and since the circumstances that drive a woman to commercial sex do not change because she has become pregnant, prostitution continues throughout pregnancy. Violence during pregnancy has obvious implications for the health of both mother and baby, and consequently has relevance for those providing maternity care (although recognition of this has been slow to develop). The relevance of violence to non-pregnant women is often only viewed in terms of rape. However, violence can cause or affect other gynaecological conditions, as well as having implications for other types of reproductive health care. It is therefore important to recognize that the entire spectrum of violence against women is of relevance to all aspects of reproductive health care.

The last 20 years has seen a worldwide increase in recognition of the health consequences of violence against women and the large spectrum of types of violence. This was accompanied by considerable research, the findings of which are supported by ongoing work in this area (Tjaden and Thoennes 2000, Watts and Zimmerman 2003).

Prevalence

The true prevalence of violence against women is difficult to determine. This is largely because of underidentification, but also because prevalence will depend on the definition of violence adopted. Studies in many countries have produced a range of estimates of prevalence for various categories of domestic violence and/or abuse. While the figures vary according to the type of abuse recorded, all are likely to be underestimates. The World Health Organization’s Multi-country Study on Women’s Health and Domestic Violence Against Women (2005) surveyed 10 countries, representing diverse cultural settings including urban and rural areas within the same country. It obtained information from over 24,000 women. The prevalence of women who reported episodes of domestic violence ranged between 15% and 71%, with the greatest amount of violence being reported in provincial settings in Bangladesh and Peru. In countries where large cities and rural areas were studied, partner violence was consistently higher in provincial settings. Women’s attitudes to violence and acceptance also varied; violence was condemned in urban areas, whereas in some rural areas, violence was accepted and justified, especially in situations such as female infidelity.

In the USA, estimates ranged between 2 million (United Nations 1995) and 4 million battered women, with 2000 women murdered each year (30% of female homicides) in association with battering (Jones 1997). In a Canadian survey of 12,300 women, 29% reported that they had experienced violence from a current or previous marital partner since 16 years of age (Johnson and Sacco 1995). In the UK, the Home Affairs Select Committee Report on Domestic Violence (1993) concluded that domestic violence is ‘common’. While the 1992 British Crime Survey (Mayhew et al 1993) found that 11% of women reported physical violence in their relationships, a 1993 crime survey in Islington, London (Mooney 1994) found that one in four women reported a lifetime experience of domestic violence. In a study of 930 women in San Francisco, 12% reported rape by their husbands (Russell 1982), while in a UK study of 1000 women, one in four reported that they had experienced marital rape. The prevalence of violence to prostitutes from both clients and pimps (regardless of whether or not the latter is the regular sexual partner) is also difficult to assess. Nevertheless, its occurrence is well recognized by those who work with prostitutes, although not necessarily by the criminal justice system whose response has often been inappropriate (Kennedy 1993).

Reproductive Health Consequences

Women who experience violence are more likely to suffer a number of consequences relevant to reproductive health services. More than 30% of domestic violence begins during pregnancy (CEMACH 2004), and more than 14% of maternal deaths occur in women who had told their health professional that they were in an abusive relationship (CEMACH 2007).

During pregnancy, the injury sites include breasts and abdomen with consequent risk of injury to the fetus, including miscarriage, premature delivery and fetal death (Mezey and Bewley 1997). Women who have experienced violence are more likely to suffer miscarriage (Stark and Flitcraft 1996). Pregnancy, genital tract infections and genital tract injury are possible consequences of sexual violence, while other persistent gynaecological problems, especially abdominal pain, may be the presentation of abuse. Such women may find it difficult to undergo pelvic examination.

Obviously, in all of these situations, the converse does not apply and not all women with such problems or difficulties have been abused. Equally, many women who have been abused demonstrate no obvious problems or stigmata which might indicate a history of abuse.