Dip Obs

1. Gender Based Violence
Themba Hospital DipObs Tutorials
By Dr N.E Manana

2. Introduction
• Women around the time of pregnancy can experience harm by current or
past partners, or by others who live in their home.
• Health workers are in a good position to respond to GBV.
• This response is also now mandated by South African legislation and policy.
• The Domestic Violence Amendment Act (2021) requires that health
workers are given the skills and tools to respond to GBV among patients.
• Maternal Perinatal and Neonatal Health Policy states that GBV prevention
and response is an “essential life-saving intervention.”

3. Types of GBV
• GBV may present for the first time or become more severe during or after pregnancy.
• Gender-based violence (GBV) refers to any type of harm or threat of harm towards a
person because of their gender.
This can take many forms, including:
• Physical: hitting, slapping, pushing, choking, pulling hair, threatening or actually using
a knife or gun
• Sexual: forcing to have sex or coercing into a sexual act
• Psychological: threats, stalking, humiliation, or controlling movements (including
limiting her access to family or clinics)
• Financial: withholding money, banning woman from working
• Technological: sending threatening messages, stalking online, tracking woman’s
whereabouts through social media
• Prevalence of GBV in pregnancy in South Africa is estimated to be 1 in 4 women

4. Untreated GBV
• Pre-conception – 50% higher HIV incident infection, decreased contraception
use, high-risk sexual behaviour, and unwanted or unintended pregnancy
• Pregnancy – twice the odds of perinatal death, preterm labour, antepartum
hemorrhage, miscarriage, vaginal bleeding, high blood pressure, worse uptake
of antenatal care, lower skilled birth attendance, depression symptoms,
anxiety symptoms, post-traumatic stress disorder
• Newborn – twice the risk of infant and neonatal death, stillbirths, pre-term
delivery, low birth-weight, worse maternal viral suppression (increasing
vertical HIV transmission)
• Infancy and childhood –infant illness (e.g. diarrhoea), worse immunisation,
stunting, developmental delays, learning impairment, emotional
dysregulation, mental health difficulties, increased likelihood of child abuse

5. GBV in pregnancy
Possible signs that a woman is experiencing violence:
• Withdrawn, avoidant, or combative during antenatal care
• Partner insists on attending antenatal care with the woman
• Not able to follow medical advice, such as adhering to HIV treatment
• Multiple parity (especially unwanted or unintended pregnancy)
Risk factors for maternal mental health conditions
• Living with a chronic disease including HIV; poor social support (including
being a refugee or asylum seeker); childhood exposure to family violence
or rape / incest; current alcohol or substance misuse; poverty or food
insecurity

6. How can you identify a woman who is
experiencing GBV?
Safe, private space:
• First, invite her to talk with you in a quiet, private space in the clinic.
• If she is accompanied by a partner or family member who may be harming her, say
that you need to do a medical procedure with the woman in private for a while.
Use empathic skills:
a. Show kindness with your words, your voice and body;
b. Listen to her story calmly and attentively
c. Reflect her feelings without judgement.
• Why screening can be an intervention. Just this step of asking kindly and calmly
about something happening in the woman’s life can be helpful.
• Even if patients do not tell you much, they will know that the health clinic is a place
where someone cares about them, and they might choose to disclose their
experience at a future clinic visit.

7. Ask about the relationship “Are you afraid of your partner?” • Yes • No
1 0
Ask about worries for child
safety
“Do your children feel unsafe at home?” • Yes • No
1 0
Directly ask about physical
GBV
“In the past year, did you ever get hit, slapped,
punched or hurt in some other way at home?”
• Yes • No
1 0
Directly ask about sexual
GBV
“In the past year, were you ever forced to have
sex when you didn’t want to?”
• Yes • No
1 0
TOTAL SCORE 0: no additional care needed
1+: First Line Support and refer for additional services
For those responding with TOTAL SCORE of 3 or 4: Check for Danger
Check for current danger “Do you believe your partner might harm you
or your child in the next few days?”
• Yes • No
If Yes, ask if she would like an immediate
referral to a shelter

8. First Line Support
Your job is not to solve the problem of violence, but instead to help her get help outside the clinic. This is called “first-
line support”.
1. Explain that your job as a health worker is to support her to make her own decisions, and to respond to her most
immediate concerns.
2. Help her to explore her options and the advantages and disadvantages of these. Assist her to develop a step-by-
step plan that is manageable for her. If you can, see her again to check how her plan is going. .
3. Help her find additional care if she wants this:
• For victims of rape, administer Post-Exposure Prophylaxis (PEP) within 72 hours. Refer her to a Thuthuzela Care
Center.
• Gender Based Violence (GBV) Hotline: 0800 428 428
• National Shelter Movement: 0800 001 005
4. Many women will not want help or a referral immediately.
a. Do not pressure them to act immediately. It’s important to respect their decisions – they will know best when it
will be safe for them to act.
b. b. As a health worker, you can play an important role in supporting and empowering a woman during this
process.
c. If you can arrange to see them again in the clinic, you can offer valuable continuity of care.

9. Safety Planning
• GBV survivours are often very skillful at telling what times are more dangerous than others.
• If the patient feels safe right now, you can help her plan for a future crisis now, while things
are calm.
Many women want or need to stay with a partner or another person who is violent towards
them. Even in this situation, it is possible to prevent new episodes of violence by helping
them with a Safety Plan:
1. Help her to identify a safe person to disclose the violence to (family member, friend,
neighbour). Then, she could ask them if she could send them a code if she is in danger, to
alert them.
2. Encourage her to organise her important documents and keep them ready and in a safe
place if she needs to leave in a hurry (birth certificates, marriage certificates, ID, SASSA or
bank card).
3. Advise her to have a ready-packed bag with basic necessities for herself (and her children)
if she needs to run away or go to a shelter. She can keep this at a friend or relative’s house .
4. Ask that she teaches her children to run to a room with a locked door or a safe neighbour’s
house if an argument breaks out. This can prevent children from getting hurt.

10. What about the health worker?
• It can be difficult to listen to stories of violence in the lives of our
patients.
• We may also have been affected by the same situations in our
personal lives.
• It is important to recognise that our role is to assist and not to fix.
• We also need to take care of ourselves in doing this work to protect
our own mental health and to ensure our ability to be effective
professionals.
• See free HealthCareWorker HCW Connect resource on WhatsApp 060
060 1111 or SADAG helplines: 0800 21 22 23 or 0800 456 789.

11. THANK YOU