Written by Dr Jyoti Vikas Rokade, Associate Professor, Department of Obstetrics and Gynaecology, Government Medical College, Miraj.
Project implemented by Miraj Medical College in collaboration with the Centre for Enquiry into Health and Allied Themes and the World Health Organization
Mukta means to be free from all restrictions, free to live one’s own life, with one’s principles and without any domination.
After working on the MUKTA project for about a year, we felt it was time to share something about our contribution.
Violence of any kind, towards any person, is an unacceptable act performed from a position of dominance and power. Different sectors of society are working towards addressing the sensitive issue of violence. Violence against women remains an unaddressed and unresolved issue around the world. It ranges from verbal to physical and sexual abuse, and sometimes murder. Intimate partner violence is part of domestic violence.
Women who experience violence are affected physically and, often more so, psychologically. In these cases, health care providers (HCPs) can provide much support. Women who come for health care may intend to disclose more information, but by the time they reach the HCP, they decide against it and share only minor details. If the HCP is not trained to listen keenly to patients and observe that there is more to the issue than what he or she is being told, the HCP may miss the clues that indicate abuse, and patients will only be treated symptomatically. It is, therefore, the responsibility of HCPs to be attentive to identify these cases and to provide essential services. HCPs are in a unique position to create a safe and confidential environment that encourages victims to disclose violence, offer appropriate support, and refer victims to other resources and services.
We recognise that violence is not only confined to women, as men are also victimised. However, studies over several years have confirmed that women suffer greater injuries than men. For this reason, we focused more on female patients.
The project, initiated by CEHAT and WHO, aimed to identify female victims of violence and to provide them with support and referral services. We are pleased that two local colleges from Maharashtra were selected to carry out the project and have become champions of this project. One was Government Medical College, Miraj, and the other was Government Medical College, Aurangabad. The Departments of Medicine, Casualty, and Obstetrics and Gynaecology were closely involved with the project. Our first meeting took place in April 2018, where we were informed of the project and its proposed timeline.
The proposed timeline for the project was 18 months. During this time, we - as trainers - were to train the HCPs at our institutes. Our group consisted of doctors from the above-mentioned departments, as well as nurses and the Social Service Department staff. Each college was assigned a nodal officer for future communication. Three days of intensive training covered scenarios in which women currently experienced violence. We were introduced to the definitions of various forms of violence against women – domestic violence, intimate partner violence and sexual violence. The concepts of sex and gender were discussed, and many myths related to domestic violence were debunked. Training also covered the keyword ‘LIVES’ (Listening, Inquiry, Validation, Enhanced safety, warm referrals and Support). We were allocated time to train HCPs in our respective institutes.
Government Medical College, Miraj (GMCH), is attached to two hospitals, namely: Padma Bhushan Vasant Dada Patil Government Hospital Sangli PVPGHS and Government Medical College and Hospital (GMCH). Almost 300 patients visit the Obstetrics and Gynaecology Outpatient Department (OPD) in each hospital each day. The staff has a high workload and were not aware of violence and its health consequences, so it would have been difficult to check if every female patient was a survivor of violence; we also felt that this would increase the consultation time required for each patient. After receiving training on assisting women who experienced violence, we were able to find ways to deal with this problem and recognised that it is possible and feasible to respond to women’s needs even in the limited consultation time in OPDs.
We were trained to identify female victims of violence. The WHO does not recommend screening every patient for violence, and it is not possible to ask each woman about suspected violence, so we were trained to identify victims in each department through specific signs and symptoms.
After we were trained, we had to train the doctors and staff nurses. It was the same training that we received, but it was to be covered in two days (instead of five). The administrative workload and the busy OPD and Inpatient Department (IPD) schedules made it difficult to allocate two days for training. Despite this, there was a very positive response from participants across different departments. Every session was interactive, and participants applied their own experiences intensively. We introduced them to the concept of registers (explained further below), as well as the importance of the Protection of Women from Domestic Violence Act (PWDVA), highlighting ‘LIVES’. On the second day of training, the trainees began working on their tasks for the project.
Four sessions were conducted one month apart. Each session was attended by 30 participants: 15 doctors and 15 staff nurses and members from the Department of Social Services. Within about four months, we had trained 120 doctors and staff nurses.
Trainees expressed their difficulty in discussing violence, the roots of violence and types of violence. Each training session included a role-play activity that examined good and bad ways of talking with patients and good and bad attitudes when dealing with patients. Training also covered body posture and included tips for listening. Each session ended with brainstorming activities.
The new registers (named MUKTA) were to be completed by trained Health Care Providers after they had identified women facing violence and offered LIVES. These registers were handed over to each department and a point of contact who would ensure confidentiality and safekeeping. Each institute had a total of six registers for the superintendents of the Medicine, Obstetrics and Gynaecology, Casualty and Social Work departments. These registers were kept in the wards as well as in the outpatient departments. Monthly statistics were taken and conveyed to the CEHAT team.
Experiences in the Casualty Ward
HCPs first encounter most women victims of violence in the casualty ward. Many of the cases reaching the casualty department involve physical assault. In instances of physical assault, a police complaint may already be lodged, and such cases are medico-legal, so patients usually voluntarily describe the violence. After patients have received primary care and are in a stable condition, they are shifted to a ward, where it is possible for HCPs to talk to them. Many patients are deeply emotional and take comfort from being listened to. Patients who need further support are referred to the social service superintendent. Care is taken to communicate all information to the relevant person beforehand, to avoid the repetition of questions that could add to the patient’s trauma.
Experiences in the Department of Obstetrics and Gynaecology
The Department of Obstetrics and Gynaecology received patients with unwanted pregnancies, severe anaemia, or those with experiences of rape or repeated abortions. It was suspected that these patients were victims of violence. After some probing, it was evident that almost all patients were experiencing domestic violence.
The strongly patriarchal system in India affects female freedom directly and is the main cause of domestic violence. We found that even though some women were able to describe their experience, they were unwilling to enter the details in the MUKTA register. These registers were for data collection and could be produced in future should documentation be required. The register was not a criminal record. Because they feared leaving a record of the assault and causing subsequent intimidation by perpetrators, some women refused to complete the register entry.
The procedure for examining rape victims was changed significantly. Medical services were confidentially provided in the consulting room. Victims had the freedom to refuse a genital examination while still availing themselves of health care. Obsolete examination methods such as the invasive practice of determining “capability to perform intercourse by use of two-finger examination” were completely stopped.
In 90 percent of sexual violence cases, it was evident that the perpetrator was either a close relative or other person known to the victim. Many patients needed intensive counselling. Smart referrals and support were significant in building patients’ well-being.
Experiences from the Department of Medicine
The Department of Medicine touches all the branches of the medical fraternity. Therefore, patients with different complaints approach the Medical Out-Patient Department (OPD) first. The workload in this department is significantly high. We trained the nurses and doctors to pick up cases reported as accidental poisoning that were failed attempts at suicide. Additionally, patients with vague complaints of headaches and body aches, and those who repeatedly complained of different psychosomatic symptoms, were also considered victims of suspected violence. Even though it was not possible to enquire about patients’ problems in the OPD, every attempt was made to respect patients’ privacy and speak to them confidentially in the ward at an appropriate time.
It was observed that most of these cases of poisoning were not life-threatening. The repeated consumption of low doses of easily available medications, such as pain killers and insecticides, was observed. This suggested that the women experiencing violence experienced a temporary breakdown in coping with violence, and because of the increasing threat of violence attempted suicide to stop the perpetrator. This implies that women are often driven to a decision to end their lives when they can no longer cope or handle the abusive situation, and tragedy ensues.
The most important concern for the patients approaching the OPD or IPD was the prevention of future abuse. About 70 percent of patients had experienced more than one episode of violence. Because many of these women lack self-respect and may even consider themselves to be the cause of the violent behaviour, they have not enforced their boundaries. After validation that emphasizes that violence of any kind is unacceptable and that everyone has a right to live a fearless life, patients were able to return to their homes with newfound confidence. During conversations between HCPs and the victims, HCPs informed victims that they could approach the MUKTA centre for help at any time. As it became evident that the MUKTA register documents incidents without any medico-legal consequences, women became more comfortable disclosing details of violent events.
The concept of a “Protection Officer” was also introduced during the training period. For every district, a government-assigned protection officer would provide legal aid and, if necessary, rehabilitation for victims and their children. The Social Service Superintendent referred three patients from our institute to the protection officer. Protection officers can provide patients with legal and, to some extent, financial aid and shelter. However, because of the huge populations and the large workload carried out by only protection officers in many districts, it becomes difficult to trace some patients.
Follow-ups with patients
It has been observed that few female patients return to seek further advice. Reasons for this could be a decrease in the level of violence (at best), financial difficulties, or reluctance to go to a health care facility without any visible and/or significant health issues caused by ongoing abuse. This issue needs to be addressed.
The MUKTA project, which focused on identifying and providing support to women who were victims of violence, is an appreciable effort by CEHAT and WHO. Our participation in the project has completely changed our attitude towards our patients: we now look beyond treating just physical complaints but actively seek to improve their well-being. Treating our patients empathetically, not just symptomatically, is the real goal.