Making the Connection Between Gender-Based Violence and Fistula Care
This blog was originally published on the USAID MOMENTUM website. It has been republished here with permission.
Since the onset of the COVID-19 pandemic, reports of violence against women and girls have been on the rise. Even before COVID-19, globally, an estimated 736 million women and girls—about one in three—have experienced rape, sexual abuse, domestic abuse, or other forms of violence at least once in their lives.1 Additionally, millions experience or are at risk of forced marriage, human trafficking, and female genital mutilation.2, 3, 4
Women living with fistula often experience stigma and abuse and become victims of violence and cruelty because of their condition. They tend to live in rural areas in Africa and Asia, with little to no access to education. Fistula can occur due to injury during childbirth (obstetric fistula), a surgical error, most often during a cesarean section (iatrogenic fistula), and through sexual violence or accidents (traumatic fistula).
Despite the availability of effective and affordable fistula care, including repair surgery, an estimated one million women in sub-Saharan Africa and South Asia continue to live with the condition given their limited access to safe obstetric care.5 Building on USAID’s past investments and accomplishments, including the work done under Fistula Care and Fistula Care Plus, MOMENTUM Safe Surgery in Family Planning and Obstetrics will continue to work closely with countries to address the obstacles that severely limit women’s access to high-quality fistula care, including maternity care and screening for gender-based violence (GBV).
To mark International Day for the Elimination of Violence against Women (November 25), we spoke with Dr. Vandana Tripathi, former Director of Fistula Care Plus, and now Director of MOMENTUM Safe Surgery in Family Planning and Obstetrics, to discuss MOMENTUM’s plans to work in this area, to help women living with or treated for fistula effectively reintegrate back into their communities and to connect GBV screening with health services and fistula care.
How would you describe the connection between fistula and GBV?
While not common, fistula can be caused by violence. For example, in the Democratic Republic of Congo, our partners such as the Panzi Hospital in Bukavu, treat women who have traumatic fistula caused by extreme sexual violence. Fortunately, this is quite rare in most settings.
However, the connections between fistula and GBV can go in multiple directions. The USAID Fistula Care Plus project and the DHS Program conducted research on this relationship in 2017 and looked at household surveys conducted in countries in sub-Saharan Africa. We found that women who reported fistula symptoms are significantly more likely to report having experienced both physical and sexual violence, including sexual violence in the past 12 months. This finding suggests that women may be at higher risk for gender-based violence because of their fistula, perhaps because having fistula makes them more vulnerable or less “protected” in their communities. Or it could be that the same women who are most at risk for fistula (because of early marriage, lack of access to education, lack of access to health care, or other factors) are also the same women who are most at risk for GBV.
How would you describe the problem of fistula and GBV globally?
Both are problems with significant global impact, although their scale is different. Up to one million women are living with fistula in low-income countries.6 For these women, fistula has a huge impact on their mental and physical health and ability to participate in society.
A large percentage of women experience physical, sexual, and/or intimate partner violence.7 We know that women experiencing GBV use health services more. However, in many settings, GBV is still viewed as an issue that is separate from health services and not consistently addressed by health providers. Some providers don’t view GBV services as “essential and life-saving,” a central part of comprehensive health care, but rather as a legal or police issue.
Why is GBV screening important?
Fistula can cause women to experience severe stigma, shame, isolation, and other consequences in their communities. Fistula programs often support women who have received fistula repairs in reintegrating back to their communities. However, fistula repair sites do not generally screen for GBV. Despite the increased risk of GBV among women with fistula, this issue has not been part of the standard package of fistula care. This means women could go back to abusive or dangerous situations, under the assumption that going ‘back home’ is successful reintegration. Fistula programs should routinely screen for GBV at intake and/or before discharge and connect women who are experiencing or at risk for GBV to supportive services.
How is MOMENTUM’s approach different or unique compared to previous work?
MOMENTUM Safe Surgery in Family Planning and Obstetrics has an opportunity to draw attention to GBV within fistula care, and to ensure that fistula services include a more holistic approach to addressing the needs of women who have experienced this devastating condition. The project will be working with fistula repair hospitals and organizations in countries such as the Democratic Republic of Congo, Nigeria, and Mozambique. In each of these countries, we will support the development of protocols for routine GBV screening and referral for all fistula patients before they are discharged from hospitals. We will also maintain lists of resources where women experiencing GBV can be referred. A key principle across MOMENTUM Safe Surgery in Family Planning and Obstetrics programming is the “Do No Harm” Framework developed by EngenderHealth. This novel approach can help fistula care programs integrating GBV for the first time connect the dots between issues that women with fistula cope with as well as protect their safety. Because disclosure of GBV can itself increase a woman’s risk for further or aggravated violence, we will work with partner hospitals to be sure that screening is confidential and protects privacy and doesn’t expose women to unintended harm or backlash. For example, if intimate partners are the source of GBV, it is critical they not be present when women are screened for GBV, and information during GBV screening is not discussed in settings or noted in documents that may be available to partners or others in the family or community.
Are there any special considerations when integrating GBV and fistula care?
MOMENTUM staff will support countries in training health facility staff, so GBV screening questions are asked in a sensitive manner and don’t further aggravate existing emotional distress experienced by women. Facility staff may also need training in providing psychological first aid counseling in situations where a survivor reporting GBV may require support to manage overwhelming emotions.
Having an up-to-date referral list for all GBV services at each health facility is one of the fundamental aspects of “Do No Harm.” The screening is not an end in itself – rather, it is the beginning of the process to provide support and services to survivors. Facility staff needs to know the location and contact information for all referral services (legal, shelter home, psychological counseling, financial aid, etc.). After screening, survivors should be referred to the required or requested services. If a facility only screens but does not connect survivors to care, this can be harmful for the woman, as she has relived the trauma by narrating her experience but is not receiving follow-up referral or services to address the GBV.
What do global stakeholders need to know?
Global stakeholders need to understand the relationships between fistula and GBV and women’s shared vulnerability to both these issues. They need to take GBV seriously as part of post-repair planning for women who have had fistula. Specifically, health providers also need easy-to-use tools to screen women for GBV, such as those developed by EngenderHealth in Tanzania in collaboration with the Ministry of Health, Community Development, Gender, Elders and Children, which can be used during interactions with patients. MOMENTUM Safe Surgery in Family Planning and Obstetrics will work in partnership with governments and civil society organizations to support the development and dissemination of such tools, building on the types of simple, innovative screening tools that MOMENTUM implementing partners have already developed for use by community health workers and organizations to find and refer women with fistula symptoms.
More broadly, we need better integration of GBV issues into health care, as well as more health providers and services for women experiencing GBV, from psychosocial counseling to shelters. The work that MOMENTUM will do to integrate fistula care with GBV is one part of the global effort to address this need and to make GBV services accessible in more health care settings.
- UN Women. Facts and figures. Ending violence against women. https://www.unwomen.org/en/what-we-do/ending-violence-against-women/facts-and-figures
- UN Special Representative of the Secretary-General on Violence Against Women. Girls. https://violenceagainstchildren.un.org/content/girls
- United Nations Human Rights. Office of the High Commissioner. Child and forced marriage, including in humanitarian settings. https://www.ohchr.org/en/issues/women/wrgs/pages/childmarriage.aspx
- United Nations Office on Drugs and Crime. UNODC report on human trafficking exposes modern form of slavery. https://www.unodc.org/unodc/en/human-trafficking/global-report-on-trafficking-in-persons.html
- Adler AJ, C Ronsmans, C Calvert, and V Filippi. Estimating the prevalence of obstetric fistula: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013; 13:246.
- Adler AJ, C Ronsmans, C Calvert, and V Filippi. Estimating the prevalence of obstetric fistula: a systematic review and meta-analysis.
- World Health Organization. Violence against women. Key facts. March 9, 2021. https://www.who.int/news-room/fact-sheets/detail/violence-against-women#:~:text=Estimates%20published%20by%20WHO%20indicate,violence%20is%20intima