“A pregnant woman was hit in the stomach by her husband, and she is bleeding.” Assault scars can also be seen on her legs and hands. Because she is anaemic, she may lose her baby or even her life.”
This is a fictitious case study, but in India, where one out of every three women experiences domestic violence, it could be very real. This fictitious survivor experience is being used to teach rural health workers how to deal with domestic violence at a training session in Gujarat’s Patan district’s Sidhpur block.
Thirty ASHA workers, or Accredited Social Health Activists, are learning how to spot signs of spousal abuse. Arti Prajapati, a counsellor at the General Hospital in Sidhpur, has advised them to keep an eye out for women who have multiple pregnancies, anaemia, tuberculosis, or 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.
They are required to make door-to-door visits and have intimate knowledge of the households under their care, making them the best positioned to identify potential victims of domestic violence. The trainers then ask them to refer any cases they come across to the three Mahila Sahayta Kendras, or women’s crisis and intervention cells, set up in Patan’s rural areas by the non-profit Society for Women’s Action and Training Initiative.
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.
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.
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.
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.
The Society for Women’s Action and Training Initiative decided to include ASHA workers in the project and began training them in 2016, four years after opening their first cell in Radhanpur. 550 ASHA workers have been trained by the Society for Women’s Action and Training Initiative in Patan’s three blocks to date.
Manjulaben, an award-winning ASHA worker from Nandotri in Sidhpur block, said she looks into whether a woman has returned to her parents’ home, which is often a sign of marital discord. “I refer them to the cell if they complain about problems in the marital home or have health issues,” she explained.