Many governments, UN agencies and NGOs acknowledge that respecting sexual and reproductive rights is essential for enhancing women's and men's sexual and reproductive health (SRH). One area in which SRH rights are particularly important is violence against women (VAW). It affects women everywhere, regardless of age, ethnic background, socio-economic class or place of residence. But women of reproductive age face the most possible consequences, because violence may be associated with an inability to prevent unwanted pregnancies, with pregnancy itself, pregnancy loss or abortion-related health care.

In addition to psychological, physical and sexual violence, institutional violence is a fourth type of VAW, comprising physical and psychological harm due to structurally inadequate conditions in institutions and public systems. It is closely related to quality of health care and the right to be free from cruel, inhuman or degrading treatment.

Violence and pregnancy

Violence may be related to pregnancy indirectly or directly. Women who have suffered childhood abuse may tend to engage in behaviours (e.g., sexual risk-taking, drug and alcohol abuse) that prevent consistent or correct contraceptive use. They may also not use contraceptives due to fear of, and actual, abuse by partners.

Pregnancy can result from rape, and if women and girls are refused the option of emergency contraception immediately afterwards, institutional violence comes into play because they are re-victimised. Teenagers who become pregnant at a very early age face health risks; deaths related to pregnancy and childbirth are 2-5 times higher among women under 18 than among those aged 20-29 years.
Some women suffer psychological or physical violence as ‘punishment' for getting pregnant, since they are seen to be challenging gender norms concerning the ‘proper behaviour of good women' and ‘family honour'. The violence perpetrated against these pregnant women can range from humiliation, expulsion from the home and beating, to ‘honour killings' to avenge the family name. Such actions are implicitly supported by judicial systems that impose no, or only light sentences on those charged with the crime. Particularly painful are the so-called "hudood" laws in some Muslim countries, which view pregnancy in single women as proof of illicit sex, thus discouraging women from reporting pregnancies resulting from rape.

Estimates on violence against pregnant women vary considerably. While there is no conclusive evidence that pregnancy itself triggers increased violence in epidemiological terms, research has shown that this is the case for individual women around the world. The frequency and severity of abuse may increase, while the violence may change in nature: instead of strikes against the head, pregnant women may more often suffer beatings against the abdomen and chest. Abusive partners may prevent assaulted women from seeking antenatal or emergency care, whereby a miscarriage might be prevented. Women who are raped may also contract an STI that could lead to higher risks of foetal death or ectopic pregnancy when left untreated (e.g., syphilis and genital chlamydia can result in pelvic inflammatory disease).

Violence and abortion

Violence may be related to induced abortions in several ways. Women facing violence by an intimate partner or who have been raped may feel compelled to terminate a pregnancy. Some women, especially adolescents, may be pressured or forced against their will into having an abortion by their partners, family members, service providers or others.
Women who seek abortion-related care may face abuse within the health-care and legal systems. Examples of institutional abuse include: deliberate provision of faulty or incomplete information regarding the safety of abortion procedures; lengthy waiting times at health facilities for postabortion care that may cause psychological distress and physical harm; intimidation, threats and other verbal mistreatment; withholding of pain relief medications as ‘punishment'; and charging excessive fees for services. When treatment for the complications of incomplete abortions is delayed, women may face serious infections, sterility and even death.

Even when abortion is permitted by law for a variety of reasons, women still seek out illegal providers because they are unaware of their rights. In such circumstances, the power imbalance between the health-care provider and woman is heavily weighted towards the provider. This permits him/her to carry out actions such as forcing a woman to accept a certain kind of contraceptive or sterilisation.
In some countries, women who have been raped must request court permission for an abortion. Sometimes the delays in obtaining this approval mean that the pregnancy is too far evolved for an abortion. Adolescents may need consent from parents or guardians to undergo a legal induced abortion. This can be a barrier to care for young women who fear talking about the cause of an unwanted pregnancy, e.g., rape by family members.

Reporting abuse

Social norms tolerating VAW can make it difficult or impossible for women to report abuse during pregnancy. When women believe that abuse is simply their lot, they are unlikely to mention it to health-care providers as a cause of injury or a potential cause of miscarriage. They thereby deprive themselves of the possibility of assistance to cope with the problem and its possible effects on their pregnancy. Women may also believe that health providers will not provide assistance, so that there is no reason to mention the violence. Health-care providers may (sub)consciously avoid the topic of violence because of:

• discomfort (e.g., when they have a personal history of violence)
• fear of offending the patient or putting the patient-doctor relationship at risk
• disbelief that violence is actually occurring
• feelings of powerlessness and lack of knowledge about appropriate help
• lack of knowledge concerning the magnitude of the problem and beliefs that do not support interventions by health professionals
• overwork and lack of time
• prejudicial attitudes that blame victims for their situation.

Suggestions for action

NGOs can use international human rights treaties to advocate for and support measures that deal with violence in relation to pregnancy and abortion. For example, they can support the work of Treaty Monitoring Committees that assess how well governments comply with conventions that they have signed, such as the Convention for the Elimination of All Forms of Discrimination against Women (CEDAW). Governments submit regular reports on their compliance to such Committees; NGOs can provide "shadow reports" to the Committees that provide supplementary information, including on the violation of women's sexual and reproductive rights.

NGOs can organise and participate in women's human rights tribunals, where women may talk about cases of abuse related to their reproductive health. By disseminating testimonies, the general public and health providers can be educated about how international human rights standards are important to guarantee reproductive health. Other strategies include:

• revising laws and regulations so that violence related to pregnancy and abortion is addressed adequately and appropriately from a gender-based and human rights perspective
• promoting and carrying out research on violence related to pregnancy and abortion, and the wide dissemination of research findings
• formulating and promoting policy guidelines related to violence, pregnancy and abortion through professional social or health associations
• developing protocols for addressing violence, pregnancy and abortion that include counselling, emergency contraception, HIV/STI treatment, access to legal abortion and post-abortion care
• promoting collaboration among health and social welfare services, law enforcement agencies and NGOs that serve survivors of VAW
• community interventions to change gender-based norms that tolerate and condone VAW (education of young people, media campaigns, promotion and recognition of positive male role models).

Every woman must be assured her rights to protection from violence and the freedom to make reproductive decisions freely and voluntarily. Multisectoral collaboration and approaches are needed so that consistent policies are implemented, and women see continuity in prevention efforts and interventions to cope with the consequences of violence.