By: Rebecca Meiksin, MPH, former HAI practicum student

Past relationships inform our interactions with a new romantic partner. Experiences in early childhood influence our health as adults. Histories of segregation shape social and socioeconomic contours of communities. As Shakespeare wrote, “What’s past is prologue” – and we can see in our own lives and communities how the past shapes the future at personal and societal levels. New research published in Maternal and Child Health Journal explores how domestic violence in Timor-Leste – considered, in part, a legacy of years of armed conflict – links to further risks for women and for new generations.

From nutrition and fertility to malaria and women’s empowerment, the Timor-Leste Demographic and Health Survey (TLDHS) covers the gamut of public health issues and gathers a wealth of information. The Domestic Violence Module, added for the 2009-2010 TLDHS, asks women about their histories of physical, sexual, and emotional violence and controlling behaviors by their partners. This means we have national statistics on these abuses and researchers can look systematically at what risks women with violent partners might face.

Timor-Leste Demographic and Health Survey, 2009-10, available here.

The TLDHS found high rates of domestic violence and marital control: 35% of women in Timor-Leste who have ever been married have faced physical or sexual violence from their partner, and 14% have had a controlling partner. Globally, we know that women with violent partners are at risk for injuries and a host of other problems, including reproductive and maternal health issues. That’s why we wanted to dig into the TLDHS data to understand how this widespread abuse might link to reproductive and birth outcomes in Timor-Leste.

We found some pretty sobering results.  In rural areas, women who have ever been married and experienced physical or sexual domestic violence had twice the risk of an unplanned pregnancy and twice the risk of insufficient antenatal care compared to other rural women. And these risks carried on to the next generation: Rural women who have had a violent partner are over three times more likely than other rural women to have a baby born smaller than average. This is especially concerning, because research shows babies with a low birthweight face higher chances of problems with cognition, attention, behavior, and physical growth.

“We have known for some time that women in Timor-Leste suffer from high levels of domestic violence,” said Dr. Mary Anne Mercer, HAI Senior Advisor, “but for the first time we have concrete evidence of the risks it brings for their reproductive health and birth outcomes. I hope it’s possible for the Ministry of Health to use these results to design maternal care interventions that will help address those risks.”

In Timor-Leste, women living in rural areas are particularly vulnerable to reproductive health risks associated with domestic violence. Photo credit: Jessica Dyer for HAI

Others have written about the years of armed conflict in Timor-Leste and its lasting effects, including domestic violence. We now know this legacy links to subsequent problems with reproductive health and birth outcomes for women and their children.

But we also know these patterns are not inevitable. The TLDHS found major differences in rates of domestic violence by district. An important next step is to look at what protects against domestic violence in some places and develop interventions that build on those factors. Qualitative research has shown that social norms play an important role. Elsewhere, community mobilization has been effective in changing attitudes and preventing domestic violence, lighting a promising path towards safer futures for women and their families.

Timorese midwife enrolling a woman in prenatal care. Photo credit: Jessica Dyer for HAI

In the mean time we know that women with violent partners, in rural areas in particular, are at higher risk of unplanned pregnancy, insufficient antenatal care, and smaller babies, so we know this is a group of women who are especially important to reach with interventions that are designed to meet their needs. HAI’s work in Timor-Leste has helped the Ministry of Health deliver high quality, comprehensive health services to women. Research like this can inform interventions that can help us reach those who need it most.

The full article in Maternal and Child Health Journal is available for those with a subscription at http://link.springer.com/article/10.1007%2Fs10995-014-1638-1. For questions about the HAI’s Timor-Leste program, contact Susan Thompson at thompssu@uw.edu.  For questions about this research, please contact the corresponding author, Rebecca Meiksin, at rebecca.meiksin@lshtm.ac.uk.