ASHAs make the difference between life and death for women who cannot seek help because they have no access to mobile phones or are too scared to use one for fear of being caught
Life had never been easy for Savitri of Gujarat’s Radhanpur village. Running the household solely on her income as a daily wage worker was slowly becoming impossible. Demands made by her alcoholic husband to finance his addiction were eating into her paltry income and increasing debts. Yet, the 40-year-old was reluctant to leave her husband despite the frequent beatings and verbal abuse. Even her three children were not spared the onslaught. But in early March, the stress became too much to handle and Savitri decided to end her life by ingesting poison. Fortunately, timely action by her neighbour, who rushed her to Radhanpur Hospital, saved Savitri’s life. She was also fortunate that doctors recognised the signs of domestic violence and referred her to the Mahila Sahayta Kendra, a crisis intervention and support cell. Run by the Society for Women’s Action and Training Initiatives (SWATI), an Ahmedabad-based not-for-profit, this cell is embedded in the hospital. After counselling by the Mahila Sahayta Kendra, Savitri filed a police complaint against her husband. But the police let him off after summoning him to the station. Soon after, the country was placed under lockdown to combat the Corona pandemic. Since then, Savitri has been stuck at home with her abuser. There has been little change in her husband’s behaviour. With the alcohol de-addiction centre closing down because of the lockdown, even the small ray of hope that Savitri had of a violence-free life is fading fast. However, Savitri is not the only one living in fear amid the lockdown. There has been a spike in complaints related to domestic violence since the shut down began in late March.
According to the National Commission for Women (NCW), complaints received by them till mid-April suggested an almost 100 per cent increase in domestic violence during the lockdown.
Gender-based violence tends to increase during a crisis as unequal gender power structures fuel dissension. In a lockdown situation, women in an abusive relationship and their children are likely to be exposed to a dramatic increase in violence as family members spend more time in close contact and families cope with additional stress and potential economic or job loss, says the World Health Organisation. Intimate partner violence affects the mental health of women, too, with prolonged stress leading to chronic health problems.
Last month, the NCW announced a special WhatsApp helpline number (7217735372) in addition to the existing 181 helpline number, to make it easier for women in distress to seek support. While this is a step in the right direction, only 38 per cent women in India own a mobile phone.
Data also show that a large number of women don’t seek help when they face abuse because they think that violence against them is warranted. According to the National Family Health Survey-4 (NFHS), over 26 per cent of girls and women (aged 15-49) think that the husband is justified in beating a woman for going out of the house without permission. While 37 per cent women said a thrashing was acceptable if a woman showed disrespect towards her in–laws, 32.7 per cent cited neglect of household chores and children as a justifiable reason and 11 per cent cited bad cooking as reasonable grounds for violence.
Since the prevalence of such social and cultural norms and lack of mobility are more pronounced among rural women, a good way to get around this has been to leverage the power of Accredited Social Health Activists (ASHAs). An integral part of the public health system, these women volunteers, usually between 24 and 45 years of age, interface between the community and the public health system. In fact, healthcare providers are often the first point of contact for women experiencing violence as they may access health services for treatment of physical and/or psychological trauma, according to research on the role of the health sector in addressing intimate partner violence by the International Centre for Research on Women (ICRW).
Thus, ASHAs are ideally placed to screen, counsel, refer and support women in their communities who experience violence. A study by the Population Council, examining the feasibility of screening and referring women experiencing marital violence by engaging frontline workers in rural Bihar, concluded that once trained, ASHAs played a vital role in bringing change. So SWATI’s decision, to make ASHAs the pivot of the response system to help identify domestic violence and prevent it at the local level, was a good one. Not only are ASHAs a part of the community but they also visit every household in their jurisdiction (one ASHA for every 1,000 people in a village) at least once a month and can reach out to vulnerable women.
Moreover, ASHAs are part of an extensive network of health workers and play an important role as part of an upward referral system. At the village level, ASHAs are supported by Anganwadi workers (AWWs), auxiliary nurse midwives (ANMs), medical officers and village health and sanitation committees. While it is the ASHA supervisors who provide the requisite support at the cluster level, it is the community mobilisers who do so at the block and district level. Another advantage is the rapport between ASHAs and block-level Community Health Centres/tertiary care hospitals. Since they bring women for antenatal check-ups, ASHAs are known at these faculties. So, if a violence prevention and support cell were to be located in a public health facility/hospital, there would be greater chances of women in need being able to get the necessary support services related to their physical and mental health.
This is what prompted SWATI to institute the Mahila Sahayta Kendra in Radhanpur Hospital, to tackle domestic violence in Patan, a predominantly rural district in Gujarat. This cell, a collaborative effort between the health department of the Gujarat Government and SWATI, is the first-of-its-kind in the State. Although it took SWATI almost three years after its institution in 2012 to get it going, recognition of the importance of health workers in addressing violence against women and including it in the Government training module for ASHAs in 2015 gave the initiative a big boost.
The initiative has incorporated several components common to the Dilaasa Crisis Centre for Women, the first hospital-based crisis centre in India, designed to respond to the needs of women facing violence within their homes and families. This is a joint initiative of the Brihanmumbai Municipal Corporation (BMC) and Centre for Enquiry into Health and Allied Themes (CEHAT) and is located at Bhabha Hospital, in Mumbai, Maharashtra. SWATI has adapted from this model and added additional features that specifically respond to the needs of rural areas. Besides training ASHAs, the capacity of medical staff at the hospital (where the cell is located) has been improved to respond to the healthcare/first aid needs of the victims and survivors of domestic violence, sensitively and appropriately. This is how Savitri was referred to the cell when she was brought to Radhanpur Hospital after her attempted suicide.
Even during the lockdown, their counsellors are constantly in touch with abused women through phone, according to Neeti Singhal, Research and Training Coordinator, SWATI. Depending on the case, SWATI also works through ASHA workers to reach assistance required to the women, she says. So far, over 550 ASHA workers in five blocks in Patan have been trained and the Mahila Sahayta Kendra has now been established in two more referral hospitals — General Hospital, Siddhpur and the Medical College and Hospital at Dharpur.
Clearly, ASHAs can make the difference between life and death for women who cannot seek help because they have no access to mobile phones or are too scared to use one for fear of being caught by the abusive partner. However, it is important to remember that ASHAs are voluntary workers. They receive performance-based incentives for delivering various healthcare services. But more often than not, these honorariums are not paid in time. Sometimes, just a part payment is made. The fact that they continue to work despite being underpaid should not be an excuse to undervalue them.
The work of ASHAs is more critical during these unprecedented times. If preventing violence against women is a priority, then those who are at the forefront of such initiatives, like the ASHAs, must be respected and protected.
(The writer is a senior journalist)