How does violence affect women's health? According to the World Bank, in established market economies, gender-based violence is responsible for one out of every five healthy days of life lost to women of reproductive age. Recent studies reveal that gender-based violence is a significant cause of death and illness in women, the result of beatings during pregnancy, marital rape, sexual abuse of girls, forced sterilization, abortions performed in unsanitary conditions, malnutrition, restricted access to health services, and a number of other abuses.
Over the past two decades, womens organizations have made gender-based violence a priority issue. As a result, violence against women has been recognized as a human rights issue that has serious impact on women's lives and their physical and mental health. This recognition extends to include sexual and reproductive rights which enable women to freely exercise their sexuality and make decisions regarding their reproductive health that is free from discrimination, coercion and/or violence.
The Platform for Action from the Fourth World Conference on Women held in Beijing in 1995 recognizes "sexual and reproductive rights as human rights because they are an inalienable, integral and indivisible part of universal human rights," according to UNFPA official María José de Alcalá. The violation of these rights is therefore a form of gender-based violence which affects women's physical and mental health.
The concept of sexual and reproductive rights that emerged from the International Conference on Population and Development (ICPD) held in Cairo in 1994 is directly linked to gender perspective, which establishes a different relationship between medicine and health. According to the ICPD Programme of Action, reproductive health "implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so." (ICPD, 7.2) As Colombian psychologist María Ladi Londoño explains, "this concept explicitly asserts the specific right of women and men to be informed and have access to a variety of methods for regulation of fertility."
One priority issue that came forth from the Cairo Conference was to promote men's responsibility in participating actively in responsible fatherhood, sexual and reproductive behavior, and all aspects involved in family health.
According to some activists in the women's movement, governments and the general public should perceive gender-based violence as a public health issue. The United Nations Development Fund for Women (UNIFEM) adopts this position, stating that "women cannot lend their labor or creative ideas fully if they are burdened with the physical and psychological scars of abuse." In 1993, The Pan American Health Organization released the study "Violence Against Women and Girls: Analysis and Proposals from the Perspective of Public Health", which clearly shows that violence against women and girls has serious psychological impact on their self esteem, weakening women's ability to function by themselves and generating feelings of incompetence. The study revealed that suicide attempts are twice as high among women victims of violence,and that women who have been raped or battered are more likely to abuse alcohol or other substances which are hazardous to their health. They are also more susceptible to depression.
Another study published by the World Bank in 1994, "Violence Against Women: The Hidden Health Burden" by Lori Heise, Jacqueline Pintanguy and Adrienne Germain, calls attention to institutions' lack of interest in documenting this phenomenon: "...almost no policy attention has been given to addressing violence against women as a public health issue, and even less to tackling its underlying causes. Efforts to gain recognition of violence as an issue warranting international concern have been hampered by lack of population-based data on abuse and its health consequences."
According to this study, there is a high rate of violence against pregnant women by their partners or husbands. Pregnant women are the preferred target of abuse and are at twice the risk of miscarriage and four times the risk of having a child with low birth weight. In Mexico, a survey of 324 randomly-sampled women revealed that 20 per cent of those battered reported blows to the stomach during pregnancy. In Costa Rica, a study of 80 battered women who sought judicial intervention against their partners indicated that 49 per cent reported being beaten while pregnant, and 7.5 per cent of these women suffered miscarriages as a result. This situation is compounded by malnutrition, the double workload and lack of access to health care services.
In Chile, a prospective study of 161 women revealed that those living in areas of political and social violence were five times as likely to have complications during pregnancy, such as pre-eclampsia, premature labor, threat of miscarriage, and gestational hypertension. Another aspect of gender-based violence is marital rape, an all too common occurrence. Another study cited by Heise, Pitanguy and Germain indicated that women in Peru and Guatemala who live with violent, alcoholic husbands were victims of marital rape on repeated occasions. In Bolivia and Puerto Rico, 58 per cent of battered women reported that they had been sexually assaulted by their husbands. In Colombia, 46 per cent of battered women reported marital rape.
One of the most dramatic expressions of gender-based violence is that linked to reproduction. In many instances, women lack the power to make decisions regarding their own sexuality or maternity. For example, some women do not use contraceptives because they are afraid of their husbands' retaliation. These men link fertility control with infidelity based on the premise that protection against pregnancy allows women to be promiscuous. Furthermore, the situation of unmarried women and adolescent girls is further complicated by the fact that little information exists about public sexual and reproductive health services. Also, many of these services do not assure confidential care because they lack adequately-trained staff or because they adopt coercive attitudes contrary to medical ethics.
Maternal mortality is another phenomenon that reveals the assault on women's sexual and reproductive rights. In Latin American and the Caribbean, maternal mortality takes on epidemic proportions. According to the "Informe Mujeres del Mundo: Leyes y Políticas que Afectan sus Vidas Reproductiva" (Women of the World Report: Laws and Policies Affecting their Reproductive Life), Latin American and Caribbean edition, recently published by the US-based Center for Reproductive Law and Policy, the current rate of maternal mortality in the region is 194 deaths per 100,000 live births: the fourth highest in the world. The primary cause is clandestine abortion: nearly 4 million clandestine abortions are perfomed each year and some 800,000 result in complications requiring hospitalization. In the Caribbean, abortion causes nearly a third of all maternal deaths.
Ten years ago, the World Health Organization took the initiative with the Safe Motherhood Program, an effort to call attention to the problem of maternal mortality and encourage governments to implement health polices in agreement with womens needs. Likewise, in 1987, the Latin America and Caribbean women's health movement launched the International Day of Action for Women's Health taking up maternal mortality as a central issue. May 28, is now celebrated throughout the region. From the start, women's health activists insisted on presenting this problem as the result of gender-based violence, manifested in the lack of health policies which meet the needs of poor women, as well as the misogynous, and authoritarian attitudes evident in health care services and the minimal resources allocated to improve the coverage of reproductive health programs in the context of privatization imposed by the neoliberal economic model. As the Brazilian physician María José de Araújo succinctly explains, there are three reasons for this chaotic situation. First, the economic crisis, which directly effects the health sector; second, the assistencialist medical model; and third, the governments lack of real political will to intervene in the health sector because they believe it to be unprofitable for the state treasury." Araújo points out that in São Paulo, one of the cities with the highest income per capita in Latin America, the government allocated a mere 6.73% of the state budget for health in 1992.
Maternal mortality has been directly linked to public coverage of childbirth, and malnutrition of mothers living in poverty further complicates their chances of healthy childbirth. Hemorrhage and toxemia continue to be significant causes of maternal mortality. A related concern is incomplete abortion which may result in infection, bleeding, or even acute peritonitis, which frequently leads to hysterectomy. Hospitals rarely assure adequate conditions for the proper follow-up of women who have had abortions, neither do they offer emotional support or counseling on available contraceptives.
If sexual and reproductive rights are the spearhead of gender-based violence, the words of Nafis Sadik, Executive Director of the United Nations Population Fund, on the occasion of International Women's Day are quite clear and obviously significant in the context of the United Nations campaign for women's human rights in commemoration of the 50th anniversary of the Universal Declaration of Human Rights: "Denial of their reproductive rights causes the deaths of millions of women each year and avoidable illness and disability to many more. For millions of women, sexual and reproductive rights make the difference between life and death. For millions more, they are the key to a life free of disease, free of abuse, and free of economic domination."
Isis International Documentation and Information Center for the UN Campiagn on Womens Human Rights
In Mexico, a survey of 324 randomly-sampled women revealed that 20 per cent of those battered reported blows to the stomach during pregnancy. (Heise, Pitanguy and Germain, 1994)
In Costa Rica, a study of 80 battered women who sought judicial intervention against their partners indicated that 49 per cent reported being beaten while pregnant, and 7.5 per cent of these women suffered miscarriages as a result. (Heise, Pitanguy and Germain, 1994)
In Chile, a prospective study of 161 women revealed that those living in areas of political and social violence were five times as likely to have complications during pregnancy, such as pre-eclampsia, premature labor, threat of miscarriage and gestational hypertension. (Heise, Pitanguy and Germain, 1994)
The average rate of maternal mortality in Latin America and the Caribbean is 194 deaths per 100,000 live births: the fourth highest in the world. (Center for Reproductive Law and Policy, 1997)
In Colombia, one out of every three women living in the countryside has no medical care during pregnancy. (Control Ciudadano, no. 2, 1998)
In the hospitals of El Salvador, maternal mortality is 68 per 100,000 live births. This figure does not include maternal deaths at home nor hospital deaths which are not registered. (Control Ciudadano, no. 2, 1998)
In Venezuela, the Ministry of Health and Social Welfare has identified the main causes of the area's problems as: increased poverty; a high percentage of births to women under 20 years of age; and the deficient medical care of the public sector. (Control Ciudadano, no. 2, 1998)
Cervical cancer is one of the leading causes of death in Mexican women, killing some 4,500 women of reproductive age each year: 12 women each day, one every two hours. (CIMAC Information Service)
According to studies from the United Nations Population Fund, in several Latin American countries 30 per cent of adolescent girls have had at least one child before age 20.