Maternal disabilities with long-lasting consequences have various adverse effects on the health and well-being of millions of women worldwide. Chronic maternal disabilities most frequently occur among women who survive life-threatening, acute maternal complications and are most widespread in resource-poor countries where maternal health services are often inadequate and of low quality (1
). Within these contexts, acute maternal morbidities have been reported among economically-disadvantaged populations, particularly those living in rural settings with less access to professional obstetric services (1
), although, as reported in this special issue of JHPN, their richer counterparts have more acute maternal morbidities that are clinically diagnosed possibly because they use services more (6
). In South Asia, acute maternal morbidities are also linked to patriarchal social structures and the low status of women who typically have limited access to skilled healthcare providers (6
). Despite the concentration of acute maternal morbidities and, hence, also chronic maternal disabilities in resource-poor countries, the social consequences that they may provoke, including violence, have received little attention.
Chronic disabilities resulting from severe acute complications include but are not limited to the following: uterine prolapse—sliding of the uterus from its normal position in the pelvic cavity into the vaginal canal; stress incontinence—an involuntary loss of urine during physical activity; and vesicovaginal fistula (VVF)—an abnormal opening between the bladder and the vagina. These chronic conditions typically trigger a host of co-morbidities, increasing the overall suffering of the affected women (9
). The co-morbidities include various health and functional problems (13
). Uterine prolapse, for example, can lead to chronic backache, urinary problems, pain during sexual intercourse, and complications in pregnancies (17
). Stress incontinence can cause leakage of urine during intercourse and orgasm (18
), difficulty in achieving orgasm (10
), dyspareunia, vaginal dryness, and decreased libido (11
). Victims of VVF suffer from urinary incontinence, which makes them vulnerable to urinary tract infections, vaginitis, excoriation of the vulva, narrowing of the vagina, secondary amenorrhoea, and the inability to carry a foetus to term even after repair (10
The combination of the disabilities and their co-morbidities can also impact on the ability of women to carry out household chores and partake in wage labour, to maintain an active social life, and to engage in sexual intercourse (20
), dramatically altering the quality of life of the affected women. The psychosocial and physical changes in women suffering from such disabilities and co-morbidities have been shown to affect relationships with their partners, communities, and the society at large (9
). A study examining the psychosocial consequences of Bangladeshi women living with fistula found that 33% had reported difficulty in maintaining a sexual relationship, with 50% reporting a significant decrease in libido, 59% a reduction in the frequency of coitus, and 45% a delay in experiencing orgasm (24
). Moreover, 52% of husbands expressed a loss in sexual pleasure with their wives.
Social consequences of women with stress incontinence and fistula commonly mentioned in the literature include social isolation, restrictions on religious practices, marital separation and dissolution (25
), rejection by family and friends (4
), poverty (4
), begging, prostitution (1
), and suicide (12
). Although women living in impoverished settings suffering from chronic maternal disabilities presumably have a lot in common, their life experiences are context-specific, reflecting their roles in the family and the community and guided by specific ideologies, cultures, and social structures that influence their acceptance in society.
Chronic maternal disability and violence in Matlab, Bangladesh
Located in South Asia, Bangladesh is a patriarchal society where women have limited education and participation in the labour force. Most women rely on their marital union for economic support in absence of the means to live independently outside the marriage. These factors contribute to their persistent low status in Bangladesh. Succession in Bangladesh is organized along the patrilineal lines; consequently, biological paternity of the child becomes a crucial social issue that necessitates surveillance and control over women's sexuality and reproduction (26
). Gender roles are clearly delineated (26
), with men and women functioning in separate spheres. Typically, men spend more time outside the household while women are relegated to the domestic sphere where their roles involve carrying out household chores, caring for family members, providing husbands with unlimited sexual access (28
), and conceiving and bearing children (29
Within such a context in Bangladesh, it is not surprising that attitudes favouring violence against women are common, and the reported prevalence of such violence is high (28
). According to the Bangladesh Demographic and Health Survey (BDHS) 2007, 49% of ever-married women of reproductive age are physically abused by their husbands, with 18% being victims of sexual violence inflicted by their husbands (32
). The Bangladesh component of a multicountry study on women's health and violence against women conducted in 2001 in the same rural area found rates of within-marriage sexual violence as high as 50% (28
). Results of this same population-based study showed that 79% of women in this rural site condoned one or more reason(s) for wife-beating (28
). A majority of women indicated that women must respond to their husbands' sexual desire, and 29% believed that violence is justified if a wife refuses her husband's sexual desire (28
Given this tendency towards violence relating to a couple's sexual life and its high acceptance, such violence would potentially occur also if a chronic maternal disability interfered further with sexuality.
The present study carried out in a rural area of Bangladesh attempted to address some gaps in the literature, providing in-depth descriptions of violence perpetrated by husband, family, and community members against women suffering from chronic disabilities, such as uterine prolapse, stress incontinence, and fistula. Qualitative data were collected from women to understand how these conditions affecting female sexual organs and their ability to fulfill gender role expectations might lead to violence in a society where high rates of violence against women are already reported.