“Structural violence is one way of describing social arrangements that put individuals and populations in harm’s way… The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people.”
 
 - PIH co-founder Paul Farmer, Pathologies of Power

 

“When unjust systems or structures prevent people from achieving good health, and from achieving good lives, this is structural violence in action,” says Donna Barry, Director of Policy and Advocacy for Partners In Health (PIH). 

In an article entitled “Structural Violence: A Barrier to Achieving the MDGs for Women,” published recently in the Journal of Women’s Health (JWH), PIH Medical Director Joia Mukherjee, Barry, and several other co-authors argue that maternal mortality continues to plague poor women in poor communities because public health interventions have not addressed the impact of structural violence. Drawing on examples from PIH’s work in Haiti and Lesotho, the authors also clearly demonstrate how women’s lives can be saved and transformed by programs that combine quality health care with determined efforts to uproot structural violence and the social determinants of disease, especially poverty, sexism, and gender-based violence.

In the late 1980s, 99 percent of the half million maternal deaths occurring each year took place in poor countries. Nearly a quarter century later, 350,000 women still die every year from pregnancy-related causes, the vast majority in the poor world. In a 2010 report on maternal mortality, the United Nations Population Fund (UNFPA) found that complications from pregnancy and childbirth are the leading causes of death for 15-19 year old women and adolescent girls in developing countries.

”Structural Violence” assesses the status of the United Nations Millennium Development Goals (MDGs), unanimously set by 191 UN member states in 2000. Three of the eight MDGs deal directly with women’s health: to promote gender equality and empower women (MDG-3); to reduce child mortality (MDG-4); and to improve maternal health (MDG-5). “[But] while elevating the status of women is intimately connected to achieving these goals…structural violence – in terms of gender inequality and the feminization of poverty – serves as a barrier to achieving the MDGs,” write Mukherjee and her co-authors.

 
 

Women in the waiting room of a clinic in rural Lesotho.

“When we focus only on providing new facilities and services, and we don’t remove the real barriers to utilization, we fail,” says co-author Sarah Marsh, former Director of Women’s Health Programs for Partners In Health in Haiti, in an interview about this article. “We have to understand that women may have other reasons for being intimidated from the formal health care system.”

Undoubtedly, the most substantial barriers to health care for poor women have been the costs – including user fees charged by health facilities, the high costs of transportation, and lost work time traveling to the nearest clinic. Women are also frequently inhibited from accessing health care by social and cultural factors, including stigma, reticence to expose highly personal matters to medical attention, and intimidation by their husbands and families.

PIH has found that one way to overcome the structural violence in this system is by changing how facility-based health care is delivered. For example, in most developing countries, family planning services are “vertical” within the health system: a woman sees a family planning nurse in a separate room from routine care, with separate registration and waiting lines. Not only can this eat away at precious time the woman could be using to care for her family or earn income, the separate waiting line may carry stigma within her community.  

PIH works to combat this trend. Nurses at our rural clinics in Lesotho offer to discuss  family planning at each visit a woman makes to the facility, regardless of the focus of her visit. This is one example of how PIH has systematically used lessons learned in Haiti, where Zanmi Lasante overcame the stigma and additional wait associated with HIV testing by offering it routinely with each health system contact – from check-ups to malaria treatments.

Additionally, pregnant women are offered transportation money and logistical assistance to reach clinics for prenatal care. Delivery plans are coordinated with the woman and her relatives, and women who live too far from the clinic are provided beds and meals at a lying-in center for the two weeks before their due date.

 
 

Pregnant women outside a lying-in center in Lesotho. These centers allow women to make the long journey from their homes to the health center before they go into labor.

“Meeting women’s family planning needs by reducing waiting times in clinics, increasing the number of providers delivering family planning methods, and improving access by delivering services in the communities helps overcome structural barriers to family planning and improves a country’s overall ability to provide universal access to reproductive health services,” write Mukherjee and her colleagues.

Another approach that directly addresses structural violence is the recruitment, training, and employment of local women as health agents. The majority of community health workers (CHWs) employed by PIH are women; in the countries profiled in the article, Lesotho and Haiti, more than 90 percent and 80 percent of CHWs, respectively, are women. Providing village women with paying jobs that are valued in the community improves the status of women in several ways.

“First, this values their knowledge of the local population and conditions,” write Mukherjee and her co-authors. “Second, it puts cash in the hands of women, which is known to improve the health of women and children. In addition, some of these CHWs were traditional birth attendants, but have now been trained and compensated to be more general community health workers and to accompany pregnant women.”

 
 

A training for maternal health workers in Lesotho.

In Lesotho, for example, hundreds of traditional birth attendants (TBAs) who had previously delivered babies in women’s homes have been trained and employed to reach out to all women of childbearing age in their villages. These maternal health workers provide community education, and help pregnant women and their families secure access to health services before delivery. As part of the program, both the maternal health workers and the pregnant women they work with are offered incentives to attend prenatal visits, deliver at the clinic or hospital, and receive postnatal care.

The JWH authors hope their article will increase awareness of practices that neutralize structural violence, and positively impact the well-being of poor women. “Although sound evidence has long existed for improving women’s survival, the will to address women’s health concretely and holistically is only recently gaining the advocacy needed to change policy,” they write. “There needs to be a global social strategy to fight for women’s lives that is inclusive of the risks imposed by structural violence and the delivery of care.” 

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