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The role of the midwife in addressing gender-based violence: a safe motherhood intervention: ICM Programme Manager Nester Moyo reports on a successful bilingual pre-conference workshop, held in Port of Spain, Trinidad, April 22, 2004.

The President of ICM, Caroline Weaver welcomed all present including the guest speaker and wished everyone success. She highlighted the day was going to bring together the challenges of learning with the joy of sharing!

Minister Eulalie James from the Ministry of Gender Affairs opened the day by expressing the view that the hosting of a regional workshop of this magnitude on the issue of GBV was timely and indicated the seriousness that midwives ascribe to their contributions to women's health. Similarities in culture and social values make it possible for midwives from different parts of this region to share ideas and experiences: Mrs James urged them to learn from each other and not 're-invent the wheel'. Referring to women's right to 'accessible and adequate health care and the widest range of family planning services', she nevertheless noted that there was powerlessness among women to change social norms in the region especially in Trinidad and Tobago, gender inequalities among poorer groups and an increase in HIV infections--all contributing to the incidence of GBV. The effects of GBV include gynaecological diseases, HIV infection, unwanted pregnancies, loss of dignity, and depression. Many, women experience psychological effects, which they, find more debilitating than the physical ones. Unsafe abortions threaten life.

It has been observed, the minister said, that medical professionals are not always sensitive to the issues of GBV and are not always aware of its nature and how it manifests in the women. Yet the health care system is well placed to identify, and refer victims of GBV. Midwives therefore need to utilise this potential by using a 'gendered lens' through which to look at their clientele and take specific measures. She closed her presentation by emphasising that midwives play, an invaluable role in collaborating with other health care providers and gender practitioners to ensure the development of networks aimed at improving the provision of women's health care services. Midwives' success is success to society.

Policies and programmes

Diana Mahabir Wyatt tackled the topic of 'Policies and programmes for addressing gender based violence in the Americas'. The presentation's main points were that GBV has been the subject of an Inter American Development Bank Study on the economic effects of GBV on societies. Health effects alone include poor nutrition, exacerbation of chronic illness, substance abuse, brain trauma, organ damage, pelvic inflammatory disease, low-birth-weight infants and abortions. Recognition of the deleterious effects of GBV is important for midwives because GBV directly affects the success of health care delivery systems.

One of the tragedies in Latin America and the Caribbean is the assumption among policy-makers that women and girls have the power to decide when, how and if they are going to have sexual intercourse. The 'Just say "No"' slogan promoting celibacy as a means to prevent the spread of HIV and STIs is taken to be a valid one. This is not accurate. Women's actions are controlled by their partners, cultural phenomena and male-dominated religious groups and judicial systems. Neither men nor women recognise that women have a right to say 'no' within marriage. The voice of professional midwives' associations as well as the testimony of individual midwives can change the quality, of life of these women.

The Inter American Convention on the Prevention, Punishment and Eradication of Violence Against Women states, 'Every woman is entitled to the free and full exercise of her civil, political, economic, social and cultural rights, and may rely on the full protection of those rights embodied in regional and international instruments.... State parties ... condemn all forms of violence against women and agree to pursue ... without delay, policies to prevent, punish and eradicate such violence....'

Despite these efforts, addressing GBV is difficult because:

* GBV is supported by culture. Culture determines the extent of domestic violence, not laws.

* Indifference from police and legal representatives: some police refuse to take GBV reports seriously, and so perpetrators are not likely to be punished. The male-dominated judiciary also supports tolerance of GBV by passing lenient sentences.

* Institutions support GBV. In hospitals where victims go for help, staff does not want to report abuse cases because they do not want to go to court to testify.

* HIV/AIDS. Many prevention programmes advocate, 'Just say "no"'. These programmes are male-dominated. Victims as young as 15 are blamed for not saying 'no'.

* The myth that sleeping with a virgin will cure a man of HIV has led to high incidence of sexual abuse of young girls.

* Some GBV programmes refuse to admit pregnant women into their shelters because they are afraid of legal action by the state or trouble with the birth. This is an area where midwives can contribute their services.

What midwives can do:

* Establish helplines for victims.

* Collaborate with NGOs who offer shelters for abused womenso that they can take pregnant women and contact midwives to offer the necessary care.

* Encourage social workers, neighbours, friends and families to take note of abandoned children who may fall victim to abuse.

* Encourage their governments to establish community police. They have been proven effective in some countries.

* Analyse all the programmes in your country, and determine whether they provide the help they purport to give.

PAHO's work on GBV in the region

Dr Amalia Elisa Ayala--a representative from the Pan American Health Organization (PAHO)--gave an outline of action in the region, including a summary of prevalence of GBV in Latin America. In El Salvador, for example, 21% of women have been abused; 3-11% of males have stated that they have been abused by women; 11-25% have experienced sexual abuse in childhood; and overall 30-60% have been violent to their partners.

In the health services, it is important to recognise the aggression. It is also important to realise that people who have experienced violence themselves will be affected when they have to respond to someone else experiencing violence. Some may see the action as normal, with no need to do anything about it.

After reminding participants of the consequences of GBV, including mortality, wide-ranging morbidity and poor sexual and reproductive health, Dr Ayala suggested that midwives could:

* Provide training for support groups

* Screen and follow-up incorporated into antenatal and postnatal care, and integrating gender issues

* Create community networks and inter-sectoral collaboration

* Always emember. "Do not victimise the victim'

* Set up information programmes for women and men, teaching men about sexuality and masculinity.

Midwifery interventions in GBV

Beatriz Peralta described a project she has implemented in Argentina. To be able to set this up she had to justify the need to the authorities, demonstrate the ability to follow up and inform and explain to all stakeholders. For the project to be accessible to women she needed to create awareness among the women about their rights. Beatriz trained the health team on issues of confidentiality, respect of the victim and the importance of documenting events. She collaborated with other organisations with the same interests. In information dissemination, she emphasised that materials used in the community must use terms that are clearly understood by the community. Workshops and drama are often effective.

Beatriz acknowledged that economic, political and social powers decide what policies are used to address the concerns of people. To be successful, midwives need always to take these forces into consideration.

Tools for midwives

Debbie Lewis, of the Trinidad & Tobago Association of Midwives, described two tools that midwives can use to address GBV, the SAVER card and the Palm card. The first is for midwives to remind them to 'Screen, Ask, Validate, Educate, Refer; the second is a small card for women to keep in their bag or pocket, containing helpline numbers and other information.

The following issues were raised during discussion.

* It would be helpful for GBV to be discussed in schools. However the Trinidad and Tobago Ministry of Health does not allow that. In Uruguay there is a school programme on human development and reproductive health. During these sessions children are informed about GBV.

* In some countries not all types of violence are a crime. It is important for midwives to understand the legal systems in their countries in order to intervene where necessary. One example is Chile. There are laws against violence but GBV is not a crime. In Ecuador, there is a law that protects women and families. The professionals have to report GBV.

* Consent process. It was discussed whether a woman should give written or verbal consent to have her abusive situation discussed with other professionals and whether this consent should be written in the patient's chart. Midwives have to be sensitive to the woman's feeling if they are given confidential information. In Trinidad and Tobago, the information is written on a separate paper. The paper is put away in an envelope, away from the chart. The midwife shares with the other midwives what was discussed. In New Zealand, women walk with their own notes. In these notes it is only noted that the question of GBV has been asked. Joyce Thompson shared that in some centres, a recognised mark is put on the woman's cards. Others who see this mark recognise that there is a GBV issue.

* Continuity of care was discussed. Women who are riving under abusive situations benefit from knowing who will be with them during labour. In public services this can be difficult.

Individual country action plans

The activity to determine country priorities in addressing GBV culminated in the 29 participants developing 14 country action plans. Common themes were:

* Writing of detailed reports and giving feedback sessions to colleagues and policy, makers on the workshop content.

* Running workshops, seminars and in some cases, drama to sensitise the populations to GBV.

* Intensified information dissemination among women, women's groups, other health care workers and midwives.

* Advocating for materials to be included in the training curricula for midwives.

* Development of information education and communication materials.

* Organise educational sessions for policy makers, political leaders and traditional leaders

* Setting up counselling services for adolescents and providing culturally appropriate information and education materials to alert women to the services available.


The evaluations showed that the participants enjoyed the workshop and felt motivated to go back home and do something about GBV. Action plans were all simple but clear and could be implemented by the participants without too many extra resources. The activities proposed have potential to make a difference to women's lives in relation to GBV even if on a small scale. This was one of the intentions--to make midwives realise that they can make a difference even if it is to the life of only one woman.

It was noted that the accurate taking of history from women is intricately linked with the quality of care that midwives give. Obtaining specific information from each woman in relation to GBV increases the chance of the midwife's ability to offer the individualised care, which has always been one of the focal points of midwifery. Therefore this workshop had the potential of adding another powerful tool for the continued improvement of the quality of care that midwives give in both the short and long term.

Way forward

The process of strengthening midwives' skills is one of the ICM's objectives, and action to support participants of this workshop in implementing their plans is seen as important. ICM member associations will be encouraged to support the plans of delegates in their country so that in the end midwives are comfortable in their efforts to address GBV. Major change is evolutionary and takes time but small changes can happen sooner.
COPYRIGHT 2004 International Confederation of Midwives
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Author:Moyo, Nester
Publication:International Midwifery
Geographic Code:4EUUK
Date:May 1, 2004
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