Domestic violence victims find succour at hospital
A hospital-based model of counselling offers victims of domestic abuse a shot at a new life
A hospital-based model of counselling offers victims of domestic abuse a shot at a new life, writes SWAGATA YADAVAR
SWAGATA YADAVAR
For years, Rima Chari’s life involved hospital trips, the consequence of eight childbirths and frequent visits to treat the injuries caused by her husband’s beatings.
The last time Chari (name changed), 35, came to Mumbai’s municipal-run K B Bhaba Hospital was because three fingers on her right hand were injured, and she could not work. “I fell,” was her default response when doctors asked her how she injured herself. But the doctors trained to see signs of domestic violence-—injuries, fractures, poison consumption, multiple abortions and pregnancies etc — kept prodding gently till she revealed that her husband hit her with a brick.
Chari and her husband were migrants to India’s financial capital from Uttar Pradesh and did rag picking to sustain themselves, but her husband was ever suspicious and controlling. He did not allow her to work, talk to others and even forbade contraceptives.
Nationally, almost one in three married women aged 15-49 years experienced spousal violence (physical/emotional or sexual) and 3.9 per cent faced violence during pregnancy, according to the National Family Health Survey (201516) or NFHS-4. Of all women who have ever experienced any type of physical or sexual violence, only 14 per cent have sought help to stop the violence; 77 per cent have neither sought help nor told anyone about the violence they experienced, the survey further revealed.
Hospitals are often the first place that women facing violence come to, but once there they rarely get the care that they need. Doctors do not recognise or willfully ignore signs of violence the women face, said experts, and treat them medically without offering social or psychological support.
Funded by National Health Mission funds’, Dilaasa centres offer to change that through a model of care that can be replicated across government health centres nationwide. Started in 2001 at the K B Bhabha Hospital, a 423-bed municipal hospital in Bandra, a western Mumbai suburb, by health advocacy Centre for Enquiry into Health and Allied Themes (CEHAT), the Dilaasa centres have reached out to over 8,000 women.
Over the two years to 2018, 5,647 women were identified as potential victims of domestic abuse, of which 2,554 cases were registered for domestic violence and 809 cases for sexual violence in the 11 centres in Mumbai, according to municipal records.
The model’s effectiveness has convinced more states, including Sikkim and Karnataka to replicate it and activate a comprehensive health care response to violence, said Sangeeta Rege, coordinator , CEHAT.
Chari would have not spoken about domestic violence, but when the doctors and physiotherapist at the hospital asked her to visit its Dilassa crisis centre, she decided to drop by. Despite the language barrier — Chari speaks only Bhojpuri despite 10 years in Mumbai — she revealed her husband’s assaults. “It is not your fault,” was one of the first things the counsellors told her and discussed a safety plan with her, strategies she could use to prevent violence, including calling the neighbours, banging the doors when the husband is violent and to negotiate with him to not hit her when he is calm.
Chari returned to the hospital over three months and gained enough confidence to ask for a jointmeeting with her husband in presence of counsellors. One of the first conditions she placed before her husband was that he should stop hitting her.It was non-negotiable, she insisted. Fortunately for her, her husband changed his behaviour.
Everything about the ward and its name—Dilaasa means reassurance—is designed to be accessible for the women who need it. Positioned in the outpatient department, near the gynaecology section where young women seek antenatal care for themselves and their children, the location gives the women the anonymity to seek support.
It is also a good place to refer and identify women who face domestic violence but may not come forward themselves. The hospital staff are trained to identify potential red flags: Women who have consumed poison, who have fractures, repeated signs of abortion, pregnancies, sexually transmitted diseases, sleeplessness and depression. The idea is to reach out to young women in the reproductive age group and intervene at an early stage of violence, including the collection of medical evidence when such cases of sexual violence come to the hospital.
“Hospitals are the right place to reach out to women facing violence because of their large catchment area,” said CEHAT’s Rege.
“The health-care system can provide women with a safe environment where they can confidentially disclose experiences of violence and receive a supportive response. Furthermore, women subjected to intimate partner violence identify health-care providers as the professionals that they trust with disclosure of abuse,” said a 2014 paper published in the Lancet, a medical journal.
Despite the fact that violence against women was identified as a health priority in 2013 guidelines published by the World Health Organization, it is not adequately understood or accepted in national health programmes.
In 2016, the Municipal Corporation of Greater Mumbai (MCGM), the civic body governing Mumbai, established 11 Dilaasa centres in municipal hospitals across the city under the National Urban Health Mission (NUHM), the urban arm of National Health Mission. Each centre has two counsellors with a social work degree, two auxiliary nurses/midwives (ANMs) or health workers and a data-entry operator. The centre staff is trained by CEHAT for a week and they in turn train a core group of hospital staff, such as doctors, nurses and administration.
“MCGM has taken the lead in establishing 11 Dilaasa hospitalbased crisis centres in 2016 and an additional three in teaching hospitals, so we can truly say that we have institutionalised a health care response to violence against women and children,” said Mangala Gomare, deputy executive health officer, family welfare and child health department.
Since it is a non-profit that works at improving health research and accountability, CEHAT wanted to establish a model for hospital-based crisis centres that could be replicated by government, be a part of the formal public health system and be sustainable.
While some women come to the centre after reading posters, others visit because they remembered a nurse telling them about Dilaasa when they were admitted. Others come through referrals from doctors and nurses .
Every pregnant woman who visits the hospital for antenatal care is also referred to the centre in between other medical tests. “We found that of all women who seek antenatal care, in the government hospitals we work in, 17 per cent have faced violence during pregnancy,” said Rege. This is about one in every six pregnant woman.
Once the violence victim is at the centre, a counsellor seeks to gain her trust. It takes time but gradually women start opening up about the abuse they face at home. Counsellors like Archana Mali, 34, from V N Desai hospital, a municipal hospital at Santacruz, know the women are not always looking for solutions —sometimes they only want to be heard.
Dilaasa centre follows the concept of feminist counselling—they discuss the socio-cultural and gender context of the problem the woman faces— and the counsellors primarily aim at empowering woman to protect themselves.
They explain to women that violence is not their fault but flows from cultural norms and power dynamics between them and their families. “The woman, no matter what social strata she belongs to, wants to keep mum about the violence,” said Mali, “We teach her ways in which she can reduce the violence, if not end it.”
In some cases, counsellors help women with injuries who come to the hospital register a medico-legal case —where the doctor examines and writes his observations in a legal document—that can be used as evidence for legal proceedings.
What is an abused woman looking for? After a session that lasts about 45 minutes, counsellors find out what is it that an abused woman is looking for: Ways to separate from her spouse, prevent violence or emotional support.
“We know we have to listen from a non-judgmental point of view,” said Chaitanya Kumari, 34, another counsellor at the V N Desai Hospital’s Dilaasa centre in Santacruz.
Chitra Joshi has been working in the Dilaasa centre at Bhabha Hospital since it began 17 years ago. When the centre was being started, Joshi, a community development officer and now the centre incharge, realised that most doctors and staff considered domestic violence a family matter.
“It was difficult to make them understand the importance of dealing with and intervening in domestic violence cases because at that time in 2000 there was no law around it,” said Joshi. Even though domestic violence was a criminal offense under Section 498A of Indian Penal Code, the Protection from Domestic Abuse Act 2005, which recognised all domestic abuse, even among unmarried women, and the Criminal Law Amendment 2013 related to sexual violence, had not been passed.
“It is a good initiative that has helped many women in seeking support,” said Rajashree Jadhav, medical superintendent, M M M Shatabdi Municipal Hospital, a municipal hospital that runs a Dilaasa centre in Govandi.
For women like Chari, the Dilaasa centres offer a chance to speak up about violence, find ways to stop it—and, possibly, a shot at a new life.
The hospital staff are trained to identify potential red flags: Women who have consumed poison, who have fractures, repeated signs of abortion, sleeplessness and depression