Strengthening the health system response to violence against women in Maharashtra, India

A young 27-year-old doctor is incredulous about his former low awareness regarding violence against women, despite treating survivors in the busy medical college hospital where he works in the state of Maharashtra in western India.

"I never looked at health complaints of female patients in the context of violence. Now, I know what I should do, and what should I say to make women comfortable," said the doctor from District General Hospital, Sangli.

He is one of over 200 health care providers trained in a new pilot conducted in three hospitals in Maharashtra between July 2018 and April 2019. The research study aimed to assess the feasibility and acceptability of rolling out the WHO clinical and policy guidelines to strengthen the ability of health providers to respond to domestic violence, including intimate partner violence, experienced by women.

An empathetic response has been key to gaining women's trust

After the trainings, based on the WHO guidelines, most health care providers became aware of their responsibility to tackle this pressing public health issue - and became agents of change with their peers.

"By looking at the wound, we can easily tell if it is accidental or assault. If a woman is saying it is assault, we should build rapport and encourage her to speak," said a female nurse (obstetrics and gynaecology), from the Government Medical College and Hospital, Miraj.

Although first-line support from health care providers to women who disclose violence has led to incremental gains in women's trust and willingness to disclose, more concerted effort is needed to protect the rights of women, girls and children to be free of violence.

As described by a woman disclosing violence to a trained provider: "The doctor said come again, if you feel like talking to me, or need any help. She also shared with me her phone number. I felt there is someone who believes me and can guide me".

Knowing the numbers of women subjected to violence in India

Globally, almost one in three women have experienced either physical or sexual violence by an intimate partner or non-partner in their lifetime. Among the Member States of the WHO South-East Asia Region, India has the third highest (35%) estimated prevalence of lifetime intimate partner violence among ever-married/partnered women aged 15-49 years.

A recent demographic health survey from India (2019-2020) shows that there has been a decline in physical and sexual violence in most states and union territories, but progress remains uneven. Maharashtra is one of the five states that registered an increase in violence against women, from 21% in 2015-2016 to 25% in 2019-20.

With the COVID-19 pandemic burdening health systems and weakening support systems, addressing violence against women needs more attention now than ever before.

Providing woman-centered care: integrating response to violence against women in existing health services

The WHO Department of Sexual and Reproductive Health and Research (SRH) and the UN Special Research Programme HRP, together with the WHO Country Office for India, commissioned the Centre for Health and Enquiry into Allied Themes (CEHAT) to work with three government teaching hospitals in Miraj, Sangli and Aurangabad.
The study addressed knowledge and attitudes of healthcare providers in responding to violence against women, as well as their skills in clinical care, linked to the training and improvements in health facilities.

A woman-centred response in a clinical and health care setting aims to provide survivors with anonymity, along with treatment and first-line support.

As explained by a woman who received care in response to disclosure of violence during the study: "Family members will ask, why you are going? What is the need to go? The only place where we can go alone is the hospital…"

Learning from research to scale-up the health system response

The experience with the three hospitals revealed that healthcare worker training to care for women subjected to violence, conducted with country and context-specificity that address personal values and beliefs, improves knowledge, attitudes, and practices among health care providers, and is acceptable to them.

"The quality of service I am providing has improved dramatically without my spending a single extra minute," said Dr Pallavi Saple, Dean, Government Medical College, Miraj. "Women who have got redressal now bring other women with complaints because they are assured of support and confidentiality at our facility."

The study was done at a pivotal moment, just before the COVID-19 pandemic. It offered crucial opportunities for collaboration and partnerships that could be leveraged during health emergencies and humanitarian crises.

The approach is now being replicated, with seven additional teaching hospitals across India receiving training from CEHAT and health care providers from Maharashtra who were trained as part of the study. It is also contributing towards the development of a national protocol and training materials for health care providers to address domestic violence, including intimate partner violence, as a complement to existing national guidelines on medico-legal care for survivors of sexual violence.

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