Physical, sexual, or psychological harm by a spouse or partner is a major factor in maternal and reproductive health, said Jay Silverman at the Wilson Center.

Silverman, a professor of medicine at the University of California, San Diego, cited a 15-country study of both developed and developing countries that found 25 to 75 percent of women have suffered from intimate partner violence at least once. And the effects are very significant, both in terms of the health of mothers and their children.

Women suffering from intimate partner violence are less likely to adopt contraception and are 46 to 69 percent more likely to have an unintended pregnancy, Silverman said. Abusive partners are 83 percent more likely to coerce a pregnancy, through forced intercourse or birth-control sabotage, and women in abusive relationships are 2.7 times more likely to seek an abortion. Women suffering from abuse are twice as likely to have a miscarriage and their children are 3.9 times more likely to have a low birth weight, while infant diarrheal diseases are 38 to 65 percent more common in children born to mothers suffering from abuse.

“There are incredible vulnerabilities that we have to address immediately,” said Anita Raj, also from the University of California, San Diego. “Gender-based violence and gender inequities work together to heighten the vulnerability of girls [and women].”

Slow Change in Jordan

Cari Jo Clark, a professor of medicine at the University of Minnesota Medical School, has worked extensively in Jordan and the Middle East on intimate partner violence. It’s an “extensive problem in the Middle East, as it is in the rest of the world,” she said.

In Egypt, 33 percent of women have experienced physical abuse at one point in their relationship, as have 36 percent of Turkish women and 21 percent of Jordanian women. Seven percent of Egyptian women and 11 percent of Palestinian women specifically report sexual abuse in their marriages.

In Jordan, 97 percent of women who participated in Clark’s survey reported that their husband’s exhibited “controlling” behaviors, 73 percent reported psychological violence, 31 percent admitted having experienced physical violence, and 19 percent reported sexual violence, she said.

The contexts impacting the occurrences of intimate partner violence in Jordan are complicated and determined by the norms of society, communities, particular relationships, and the individuals involved, said Clark. For example, according to some studies, 90 percent of Jordanian men view spousal abuse as socially acceptable in certain circumstances, such as when the wife is perceived to have committed a transgression. In the Palestinian Territories, 60 percent of men view spouse abuse as acceptable and 62 percent of women agree, Clark said.

Family ties also affect partner violence, said Clark. Living with an in-law increases exposure to intimate partner violence for women, for example, but the survey found that marriage to a close cousin is associated with a reduced risk of violence. Male members of extended families are “key partners” in ending violence against women, she said. Because of social stigma, “the family is the best – and for most women – the only source of assistance.”

Although the numbers may seem grim, “change is happening,” Clark said. More and more, women in Jordan and elsewhere are getting out of abusive relationships and creating and encouraging support networks. Forty percent of women surveyed experiencing intimate partner violence sought help outside the family, which is “actually high,” she said.  Even though divorced women experience an “intense social stigma” and perhaps financial difficulties, they “knew they were exactly where they needed to be, for themselves and for their children,” said Clark.

In India, Involving the Community

“Improving the equity and value of women and girls is a very important means of improving population health,” said Anita Raj, who has recently done work on these issues in Mumbai and rural India.

Raj surveyed and worked with approximately 200 women in Mumbai slums who were at high-risk for HIV. The women participating in the project, called RHANI (Reducing HIV Among at-risk Wives in India), attended individual and group sessions to discuss the causes of gender-based violence and its connections to their health.

“We felt it was very important to have a perspective that women should have the capacity and support to affect their lives and health,” Raj said. And, encouragingly, “a lot [of women] felt they could affect their marital relationship by talking about these issues and implementing these strategies on their own.”

Creatively, the program implemented street theater as a means to address gender-based violence and reduce social stigma around talking about the issue. It also created a sense that preventing spousal abuse was a community-wide effort, she said.

Surveys conducted three months after RHANI was completed revealed a reduced rate of unprotected sex (and therefore exposure to HIV/AIDS), reduced rate of spousal abuse, and reduced rate of sexual coercion.

Child marriage also plays a large role in intimate partner violence and child health in India, Raj said. “Those who marry as children are more vulnerable to intimate partner violence,” she said. Due to high rates of girl child marriages, rural India has a high and early fertility rate. In 2012, 150,000 infant deaths were attributed to young motherhood.

A preference for sons can lower the rates of contraception for women – young and old alike – in hopes of conceiving a son.

Raj studied youth capacity-building programs to address the health issues of early marriages and early fertility. She said surveys found 19 percent of young girls in rural areas believe they should have no choice in deciding who to marry, and 10 percent believe they should have no choice in when to marry. Eighty-six percent of young women believed that contraception should not be used in marriage.

However, community and clinical interventions are showing “amazing promise” in addressing issues of sexual and reproductive health, gender-based violence, and child marriage, Raj said.  Most importantly, they are showing progress among a wide audience, including women, men, and youth.

Transforming Attitudes

“Intimate partner violence is not just something that happens to a particular small group, who happens to be at higher risk,” Silverman emphasized, and is not unique to the Middle East or India. In 2010, according to the U.S. Justice Bureau, there were more than 900,000 reported cases of intimate partner violence in the United States.

We need to identify the programs that work successfully and adapt and scale them up in development planning, Silverman said.

Globally, there needs to be greater awareness of the pervasiveness of intimate partner violence and its effects on the health of women and children, said Clark. In Jordan, innovative and multi-sector programs, such as UNFPA and USAID initiatives can generate awareness and change, she said.

“They have the potential to transform attitudes,” Clark concluded, which is the root driver of these inequities.

Drafted by Maria Prebble, edited by Schuyler Null and Sandeep Bathala