When Phumzile Khoza* came to the central
Johannesburg antenatal clinic on a chilly day in August 2013, she was feeling
on edge. Not about the medical procedures – she already had two children – but
about talking to the nurse.
One in four South African women
experience intimate partner violence during pregnancy. Credit: Alisa Hatfield
This was her third pregnancy living
with HIV, but the first with a new partner from whom she had been hiding her
status for the past two years.
This pregnancy had been rocky from the
start. Khoza had been trying to convince her partner to join her for HIV
testing, but he refused. Without couples' counseling, Khoza was afraid to
disclose, and it was becoming harder to take and hide her daily medication of
antiretrovirals (ARV).
Khoza's partner was now regularly
slapping her, punching her stomach, and kicking her during arguments.
Khoza feared it would get worse if he learned she was HIV-positive.
Although she wanted help, Khoza
imagined the nurses would not have time to talk through her complex situation.
Plus, she had seen how angry the nurses became with women who defaulted on ARV
treatment.
Looking back on that antenatal visit,
Khoza reflected: "I was stressing about the way I lived my life, stressing
about my past, stressing about my pregnancy. And I had no one."
Shocking figures
Khoza's story is increasingly common.
An estimated one in four
South African women experience intimate partner violence in the 12 months
leading up to childbirth.
Violence in pregnancy is associated
with pregnancy loss, miscarriage and neonatal death, higher rates of postpartum
depression and poor health gains for infants.
In a systematic review
of the literature, Dr Simukai Shamu, a Medical
Research Council expert on violence, found that prevalence of
violence among pregnant women in Africa is among the highest reported globally,
and that a major risk factor for violence is HIV infection.
"Because most studies are
cross-sectional, it's difficult to tell whether violence was a result of
demands or changes in life due to pregnancy, or if the pregnancy was the
outcome of violence," Shamu told IPS.
Since early 2013, a team from Wits Reproductive Health and HIV Institute
(Wits RHI) has been interviewing women living with violence in Johannesburg.
Lead researcher Nataly Woollett said
that many women described pregnancy as a time of greater violence.
"Partly because they had to
disclose their HIV status and partly because men use the woman's antenatal
visit –where testing is virtually mandatory – as a proxy for their own HIV
status, so they are curious about the results," she told IPS.
At the same clinic, IPS met Martha
Ramphele*, who described the rapid escalation of violence that landed her in
hospital while six-months pregnant: "He started telling me that I'm a fool
and stupid. And then he strangled me and let his cousin beat me up."
Ramphele reported the incident to the
police, but later withdrew the charges to protect her safety and financial
security. She suspected her HIV disclosure led to physical abuse, but she
couldn't be sure.
No one can say precisely what triggers
violence, but often the blend of stress associated with pregnancy, the shifting
power and control dynamics, coupled with a new HIV diagnosis, are enough to
heighten conflict.
The nurses' response
Violence in pregnancy impacts
negatively on the health of HIV positive women.
Sister Marieta Booysen, a senior nurse
with the Aurum Institute, a
research organisation in Johannesburg, explained that pregnant women in violent
relationships are the most likely to quit treatment: "When you tell a patient
she is HIV-positive but she is scared to disclose to her partner, it is that
very same patient who will default on her medication later."
The Wits RHI team found that most
antenatal nurses interviewed recognised that violence hurts adherence
to ARV treatment but few know how to deal with the issue.
The poor health care response can
partly be attributed to the lack of training but it may also reflect the fact
that many nurses suffer violence at home and are afraid to respond.
Dr Nicola Christofides, an expert on
both violence and HIV based at Wits University, explained that "nurses who
experience violence in their own lives are either very sensitive to the issue
of violence in their patients' lives and very receptive, or the opposite, where
they are actually in denial and shut down."
Antenatal nurses want training to
respond to violence, the WITS RHI project found.
IPS talked to Khoza at the antenatal
clinic five months after she had first met a Wits RHI nurse of the Safe &
Sound project, which identifies violence in pregnancy and provides one-on-one
counseling and referrals in three antenatal clinics in Johannesburg.
The nurse referred Khoza to the
nearest hospital offering psychological care and counseling. "It is
nice to talk about the difficult things if you have someone who understands the
situation and gives you clues," Khoza said.
Khoza had never spoken about the
violence in her life until the antenatal visits. A few months later, she
separated from the abusive partner and is finding ways to support her children.
"I still have stress but I don't
put that in my heart. I just tell myself everything is going to work out all
right even though it is difficult," Khoza said.
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