“A pregnant woman has been hit in the stomach by her husband; she is bleeding. There are also marks of assault on her legs and hands. She may lose her baby and or even her own life because she is anaemic.”
This is an imagined case study, but in India, where one in three women report domestic violence, it could be very real. At a training session in the Sidhpur block of Gujarat’s Patan district, this fictional survivor experience is being used to teach rural health workers how to deal with domestic violence.
It is a late December morning and under the shade of a Neem tree, 30 ASHA workers, or Accredited Social Health Activists, are learning to detect signs of spousal abuse. Arti Prajapati, counsellor at the General Hospital in Sidhpur, has told them to keep an eye on women who report repeated pregnancies, anaemia, tuberculosis and depression.
Mental health counsellor Deepak Prajapati has given them tips on how to spot mental health issues arising from abuse – frequent headaches, depression, anger, constant anxiety and sleeplessness.
ASHAs, women health workers assigned to a population of 1,000 under the National Health Mission, are primarily tasked with issues related to maternal and child health – nutrition, family planning, immunisation, first aid among others.
Required to undertake door-to-door visits, they have intimate knowledge of the households under their care and are best positioned to identify likely victims of domestic violence. They are then asked by the trainers to refer any cases they spot to the three Mahila Sahayta Kendras, or women’s crisis and intervention cells, set up by the Society for Women’s Action and Training Initiative, a non-profit, in Patan’s rural areas.
In this, the second part of our series on the importance of public health intervention in domestic violence, we look at the role of frontline health workers. As we pointed out in the first part, domestic violence is widespread in rural India.
It takes a heavy toll on women’s sexual, physical and mental health. Survivors of domestic violence are twice as likely to suffer injuries and depression; they are also more likely to have low-weight babies and run the risk of sexually transmitted diseases.
These linkages make domestic violence a public health issue. With rural women more vulnerable, frontline interventions such as the Gujarat experiment involving ASHAs become imperative.
The Society for Women’s Action and Training Initiative has set up assistance cells for women in three rural hospitals in Patan – Radhanpur, Sidhpur and Dharpur. We travelled to all three to understand how the ASHA network can be effective in dealing with gender violence.
ASHA workers intervening in cases of domestic violence told BehanBox that the biggest challenge they face is ensuring their own safety. They are more comfortable dealing with vulnerable women who have returned to their parental homes than those who choose to stay with their husbands. There is always the danger, they said, of the man’s family threatening an ASHA worker for interfering in a marital discord.
The ASHA advantage
As the session in Sidhpur ends, ASHA workers are asked to draw up a list of women they think are facing violence at home. Almost each comes up with 10 names from their village. However, referrals to the Sidhpur cell have been low during the pandemic and the session is a bid to help ASHA workers handle their task more efficiently. “Any woman with even repeated complaints of fever can be a sign of potential abuse at home and should be referred,” Arti said.
The Indian public health system in rural areas consists of sub-centres (for a population of 5,000), followed by Primary Health Centres (30,000 persons) and Community Health Centres (1,20,000). This network is topped by a tertiary care hospital.
An ASHA worker who caters to a population of 1,000 is considered a health “volunteer” – though this is something ASHAs have been protesting as BehanBox has consistently reported.
Only a small section of women facing domestic abuse visit a tertiary care hospital in rural areas. So it becomes critical to offer support at the village level and ensure early detection and prevention. This is why upward referrals from the sub-centre level become important.
Preventing domestic violence is part of the ASHA workers’ training module but as they struggle with a massive workload, it does not get the attention it needs.
An internal analysis by the Society for Women’s Action and Training Initiative we had access to, shows how effective the health workers can be in this respect – referrals from ASHA workers accounted for 9% of the cases referred to the cell in Radhanpur. These included instances of emotional and financial abuse not referred by the health system.
Around 2016, four years after opening their first cell in Radhanpur, the Society for Women’s Action and Training Initiative decided to include ASHA workers in the project and started training them. Till date, the Society for Women’s Action and Training Initiative has trained 550 ASHA workers in the three blocks of Patan.
“If a woman has a low haemoglobin count but doesn’t take iron and folic acid tablets despite reminders, we ask for the reason. Then she may say: ‘I have tensions’. So we probe further and that is how we sometimes end up referring her to the cell,” said Amrutaben, an ASHA worker with nine years of experience.
Manjulaben, an award-winning ASHA worker from Nandotri in Sidhpur block, said she investigates if a woman is back at her parents’ home, often a sign of a marital discord. “If they complain about problems in the marital home or have health issues, I refer them to the cell,” she said.
In a field study conducted by the Society for Women’s Action and Training Initiative to understand the efficacy of the ASHA network in the campaign against domestic violence, health workers were asked to interview women who were likely abused by their husbands.
Upto 1,181 cases were identified by ASHA workers, and 89% of them reported violence. In 78% of the reported cases, ASHA workers were approached for help.
During various waves of the pandemic, the outpatient departments of public hospitals had been shut and this meant that the crisis cells had to suspend operations. There were no new referrals from the health system even as evidence piled that domestic violence was rising across India.
Once the pandemic abated, counsellor Pragya Chauhan and assistance counsellor Kailashben started visiting the sub-centres close to Dharpur and asked the ASHAs to call suspected survivors of domestic violence. The team became something of a mobile counselling unit and the duo visited all the 44 sub-centres in their block once every two months.
This regular engagement worked: from June 2020 to August 2021, ASHA workers in the area reported 680 suspected cases; of them, 402 (59%) complained of domestic abuse and 182 of these registered a case with the cell. ASHA workers also proved to be useful in monitoring and tracking women who had approached the cells earlier.
Pragati* had returned to her mother’s home because her husband was jobless and drank all day. He landed up there, created a scene and hit Pragati. When Manjulaben, the ASHA from Nandotri, saw this she took Pragati to the Sidhpur cell.
Arti counselled Pragati on what she should do if returned to her mother’s home – call the 181 helpline and connect with her. In subsequent meetings, Arti called the husband for mediation. He said he wanted her back and feared that she would leave him.
This, he was told, would not happen till he quit drinking and abusing her and found himself a job. Not only did he appear for the mediation in the following months but also convinced Pragati to give their marriage another chance. “I recently had a follow-up call with her, she said that her husband is working now and she is well,” said Arti.
The Society for Women’s Action and Training Initiative is collaborating with the Gujarat health government to conduct ASHA training sessions in five more blocks.
For this campaign, it is important to create a support network that includes both health workers and other primary health level staff but the high turnover among specialists and the heavy workload of junior doctors makes this hard, said Poonam Kathuria, director, Society for Women’s Action and Training Initiative.
* Names have been changed to protect identity.
This reportage is part of the SWATI and BehanBox fellowship on rural health sector response to gender based violence in Gujarat.