Results of the characteristics on fertile age couples in Bali, 2015.
The island of Bali, as part of the Republic of Indonesia, is predominantly Hindu and generally follows a patrilineal kinship system. There is a link between the patrilineal kinship system and incidents of violence against women. The purpose of this paper is to describe the incidence of domestic violence /DV that has been experienced by pregnant women in the last 12 months in Bali. The study design was a mixed method, namely quantitative-qualitative. The research samples were pregnant women in the third trimester in the Pedungan Traditional Village area in Denpasar City (31 people) and the Nongan Traditional Village in Karangasem Regency (33 people). Data collection was carried out in 2015 from June to August. Forms of domestic violence incidents experienced by pregnant women in the last 12 months were more pregnant women in Nongan Village experiencing sexual abuse (3 people /9.09% vs. 2 people / 6.45%)), economic abuse incidents (8 people /24.24% vs. 2 people/6.45%) compared to pregnant women in Pedungan Village. History of DV in the form of physical violence, social violence and emotional violence. The negative impact felt by pregnant women who are victims of DV, especially psychosomatic complaints, even to the point where they intend to suicide, delayed in doing antenatal care and miscarriage. It is necessary to improve the role and competence of midwives in early detection of DV in pregnant women who have their antenatal care at a health facility and cross-sector cooperation.
- Domestic violence
- pregnant women
- sexual abuse
- economic abuse
Indonesia is an archipelago with 17,550 islands. Indonesia has a variety of different cultures from one island to another. The majority of religions embraced by people in Indonesia is Islam. In Islam there are some controversial issues related to gender relations, including the question of the origin of women’s creation, the concept of inheritance, witnessing, polygamy, reproductive rights, divorce rights, and the public role of women. If at a glance the text of the verses relating to the problem suggests an imbalance or injustice towards women .
According to data from the National Committee for the Protection of Women and Children in Indonesia in 2019, there were 431,471 cases of violence against women. This figure is an increase of 693% from 2008 which was only 54,425 cases. This data is the tip of the iceberg, because there are still many unknown events. In 2019, 66 cases of violence against women, especially domestic violence, 41 cases of violence occurred in the workplace, 39 cases of violence occurred in public spaces, 14 cases of violence against women, 11 cases of violence in media facilities, and 6 cases of violence were reported experienced by migrant workers. The most common form of violence against women was sexual violence committed by friends or neighbors of victims.
The Bali Island is one of the provinces in Indonesia which has been known to have very high artistic and cultural appeal. The majority of the population on the island of Bali is Hindu. Data based from the central statistics agency of Bali Province in 2014 reported that amount 3,729,893 out of 4,365,107 people on the island of Bali are Hindus. The controlling holder of Balinese life is the customary village or
Problems that are very closely related to gender issues include violence against women, and this condition occurs across countries, cultures and religions. Violence against women can occur throughout a woman’s life and has a negative impact on women’s health in the future. Domestic violence is the most common part of violence against women. In fact, there are still many women who do not realize that domestic violence must end. This is due to ignorance, culture, religious values, beliefs and the lack of optimal laws and regulations regarding the eradication of violence against women. The problem of domestic violence is considered as the domestic domain, not the public domain [3, 4].
Incidence of violence against women especially among pregnant women triggers a high risk of miscarriage, unsafe abortion, premature labor, and fetal distress, pregnant women who are late in checking their pregnancies, low nutritional status, contracting sexually transmitted diseases (STDs), unwanted pregnancies, as well as other infections [5, 6, 7, 8]. There is a relationship between violence against women and the birth of low birth weight babies (LBW) especially in developing countries. Approximately 16% of all maternal mortality in India during pregnancy are a result of DV [9, 10].
Domestic violence is influenced by several factors that are interrelated with one another, as described in the “ecological framework. In the context of this research, the term used is domestic violence (DV) which can also be referred to as domestic violence (DV) . The definition of gender-based violence according to the United Nations (1993), when it ratified the Declaration on the Elimination of Violence against Women, is:
“Gender-based violence includes actions or attempts to dominate men against women, including actions that can injure physically, mentally, socially, sexually and various forms of action that degrading the dignity of women” .
“The term “violence against women” can occur in both the private and public sphere and is experienced throughout the life cycle of women. Violence can take the form of beatings or hurting physically, emotionally, sexually and even socially” . There is a term intimate partner violence (IPV) which is another form of violence against women. Acts of violence are generally carried out by their closest people or partners. The resulting impact is also very large on the health and well-being of women. The point is that women must submit to men and follow the rules they make .
The terminology of gender-based violence or violence against women that is commonly used is a model of violence in the domestic sphere. Domestic violence acts in the domestic sphere or household is a hidden stigma . Domestic violence (DV) is a threat or abuses physically, psychologically and emotionally to women by other people who have the power to suppress and even force victims/women in the household . Typical interpreters are people who are known or close to the victim, namely: husband, girlfriend, intimate partner, siblings, in-laws, in-laws, friends and other people. There are different patterns regarding perpetrators and victims of violence based on gender. More violence experienced by men is obtained from the social or public environment, while violence against women is carried out by social relations or people who are closely related to women .
This research was a mixed method (quantitative-qualitative) which was conducted from June to August 2015. The samples involved were pregnant women in the third trimester in the Pedungan Traditional Village area in Denpasar City (31 people) and in Nongan Village in Karangasem Regency (33 people). The location selection was based on the consideration that the two areas represented the living conditions of the people in Traditional Villages in urban areas and in rural areas in Bali. Traditional Village is the foundation of community life in Bali. The instruments used were self-reported questionnaires, in-depth interview guides and observation sheets. The data collector recorded the results of the interview using a recorder which was then translated into notes.
Quantitative data analysis used univariate test in the form of proportions, bivariate analysis with Chi-square test. Qualitative analysis with content analysis. Data on the history of violence by husbands were obtained from husbands through in-depth interviews. Due to confidentiality and safety reasons from the respondent, the researchers explored information about the history of DV incidents experienced by women without their husbands. Likewise, when researchers asked for information about acts of violence against women that had been committed by husbands in the last 12 months. Researchers also provided some equipment in the form of tissues and candy when collecting data because the questions were very sensitive and caused respondents to recall painful events they had experienced. The husbands of pregnant women were also included in this study. Questions to husbands were related to their previous experience in the last 12 months, whether or not they had committed acts of violence against their wives and what was the reason.
3. Results and discussion
3.1 Domestic violence form
There are several forms of violence against women according to the life cycle according to the World Health Organization (WHO), namely: pre-birth, infancy, girlhood, adolescence and adulthood, and elderly. The form of violence in the pre-birth phase is in the form of abortion due to gender selection and due to blows and kicks on the mother’s stomach. Child marriage, female genital mutilation, physical, sexual and psychological abuse, incest, child prostitution and pornography is a form of violence that most often occurs in girlhood phases. Dating violence and courtship violence (e.g. rape or forced sex with threats), forced sex work due to economic pressure (e.g. marital rape, dowry abuse and murders), partner homicide, psychological abuse, abuse of women with disabilities, and forced pregnancy is a form of violence that most often occurs in adolescence and adulthood phases .
Based on data of National Commission on Violence Against Women of Indonesia (2020), recorded that the most reported area of violence cases is domestic violence (DV) or personal sphere. The percentage reached 69% of the total cases during January–May 2020. This was followed by violence in the community (30%) and state (1%). Women experience higher incidence of violence due to low education, economic dependence, parenting in families that accept violence and give boys special treatment. Studies estimate that, from country to country, between 20 and 50 per cent of women have experienced physical violence at the hands of an intimate partner or family member .
Forms or manifestations of violence against women include physical, emotional or psychological abuse, sexual, social and economic abuse [9, 15, 17, 18, 19]. According to Digest (2000), found that physical abuse such as slapping, beating, arm twisting, stabbing, strangling, burning, choking, kicking, threats with an object or weapon, and murder. It also includes traditional practices that harm women’s reproductive health, such as genital mutilation and sexual abuse. Psychological abuse takes the form of threats that can cause deep trauma to the victim. Economic abuse includes actions such as not providing expenses or income to the wife/partner to pay for household needs, as well as costs for maternity care and access to health care facilities. Social abuse includes the perpetrator prevents the wife/woman from meeting or socializing with friends including relatives and other close family members. This includes blocking the use of means of communication/telephone [5, 8, 9, 15, 16, 18, 20, 21].
In general, the role and function of midwives in the community regarding early detection and management of women victims of DV is still very limited, especially in Indonesia. The results of a study conducted by the National Committee for Women in Indonesia (2019) obtained data from 2008 to 2019 there was an increase in the incidence of violence against women from 54,425 cases to 431,471 cases. The increase in cases is almost tenfold. The most reported form of violence against women was DV, amounting to 71% or as many as 9,637 cases. The highest reported forms of DV were physical violence (3,927 cases/41%), sexual violence (2,988 cases/31%), psychological violence (1,658 cases/17%) and economic violence (1,064 cases/11%). The province known for the highest domestic violence report until 2019 was West Java (2,738 cases), followed by Central Java Province (2,525 cases), Capital city of Jakarta (2,222 cases). Data from the Integrated Service Center for the Empowerment of Women and Children in Denpasar City (2019), it was found that there was an increase in the number of cases of domestic violence from 2014 to 2018 by more than 100%, from 4 cases to 47 cases. The cases of sexuality also reported increase from 4 cases to 16 cases or increased fourfold from 2014 to 2018. Unfortunately, the incidence of violence during pregnancy is not available data in a large scale. The results of a study in Bali (2015), found that as many as 1 in 4 pregnant women have been victims of violence by their husbands or partners in the last 12 months .
3.2 Pregnant woman and partner characteristic
There was a significant difference in the characteristics of the respondents according to the level of education of the mother and the husband’s education. Gender inequality [22, 23], culture, norms, values, beliefs [8, 9], lower socioeconomic status  as a risk factor for domestic violence among pregnant women. Male partners who abuse alcohol or use drugs, are unemployed or intermittently employed, have less than a high-school education is the cause of the increase in violence against women [23, 25].
The ecological framework in violence against women includes: individual level have been a victim of violence in the family, for examples: become addicted to alcohol and illegal substances and parenting; relationship level (such as family, friends, intimate partners and peers may influence the risks of becoming a victim or perpetrator of violence); Community level (social relationships occur, such as schools, neighborhoods and workplaces, also influence violence); and societal level (influence whether violence is encouraged or inhibited. There is an understanding that acts of violence are considered as a natural thing for men to do against women to maintain economic stability, avoid social conflicts, and even perpetuate subordination. [3, 9, 19, 21, 23, 26, 27, 28] (Table 1).
|Characteristics||Village/City (N = 64 pregnant women)|
|Pedungan, Denpasar (n = 31 pregnant women)||Nongan Karangasem (n = 33 pregnant women)|
|Women education level|
|Partner education level|
3.3 The experience of domestic violence by partner or husband
It is known that globally, more than one third of women aged 15 to 64 have been victims of violence by an intimate partner or husband. This number is consistent with global figures on gender-based violence . The condition of women in Bali, who are predominantly Hindu, has a marriage value in the form of “mesatya”. “Mesatya” is a value about loyalty to their spouse or husband and the husband family to death. Or the same as the principle of getting married once in a lifetime. No matter how difficult the problems faced when married, it must remain obedient and obedient to her husband and family. One factor that triggers the DV is that the value or belief that women or wives are the property of their husbands, the husband has the right and is accepted if he treats his wife at will [2, 19].
Differences in the incidence or experience of domestic violence for pregnant women in the last 12 months in Pedungan villages and Nongan villages with sociodemographic characteristics obtained that there was a significant negative correlation (r = −0.34) and (p < 0.05) between the age of the respondent or pregnant women in the village of Pedungan with a history of domestic violence in the last 12 months. This shows that if the pregnant woman gets older, the incidence of domestic violence is lower. Meanwhile, there was no significant correlation between the age of pregnant women and a history of domestic violence in the last 12 months (p > 0.05). The forms of violence experienced by pregnant women in the last 12 months in Pedungan Village showed that as many as 3 pregnant women admitted to experiencing physical violence in the form of: husbands throwing objects/items that are dangerous to the mother (2 people/6, 45%) and the husband threw things/objects including the mother’s pet (1 person/3.23%).
In this study, the results showed that the number of women who had experienced DV in the last 12 months in Pedungan Village and in Nongan Village was not statistically different (p > 0.05). The number of women who had experienced DV in Nongan Village was higher than in Pedungan Village (15 people out of 33 people/45.45% vs. 10 people out of 31 people/32.26%). One in four pregnant women claimed to have been a victim of domestic violence by her husband in the last 12 months. Some respondents said there was a desire to leave their husband/partner, but this desire was rejected by parents . The incidence of physical violence and sexual violence was more experienced by women in Nongan Village than in Pedungan Village (6.45% vs. 3.23%). On the other hand, incidents of sexual violence and emotional violence were mostly experienced by women in Pedungan Village .
The influence of traditional and religious values is very strong, especially in regions that still carry patriarchy. Women must be obedient and submit to their husbands and families [6, 7]. Almost all women who have been victims of DV in the study said that they never told others about the violence, including their family or parents. Shame, fear, and even being blamed are the main reasons women victims of violence do not share incidents of violence with others. Domestic problems are a big shame to share with others or taboo [5, 9, 10, 15, 21, 30]. This condition can worsen the situation of women. According to Kyriacou et al. (1999) suggest that women as wives are considered as the property of their husbands .
There is an assumption among Balinese women, that husbands have rights over women including how a woman is treated. The results obtained through self-reported questioners regarding the knowledge and attitudes of pregnant women about domestic violence, that most wives agree that a wife must always obey and follow the husband’s orders. A husband can scold his wife for not obeying her wishes . Women or wives in Bali still adhere to the concept of marriage, which is the embodiment of loyalty until death. The divorce process is also very difficult, because it must involve the role of traditional leaders before the court decision [2, 19, 31].
Balinese women are synonymous with individuals who obey and follow the decisions of men, especially husbands. A married Balinese woman must follow her husband, including living in a male family. In the environment where the husband lives, it is not uncommon for the wife or woman to live in an extended family, namely with the parents of the husband or in-laws, relatives of the husband or in-laws and even other family members. This condition is suspected to have triggered acts of domestic violence against women, especially wives. Balinese society in general adheres to a fatherly system (Vederrechtelijk) or in Balinese terms it is called “Purusa”. The main thing that is understood from the fatherly system in Bali is the position of men as “Sentana” from the Purusa family line. The men who is the heir in the family [2, 31].
3.4 The history of physical, emotional, sexual, social and economical abuse
The problem faced by pregnant women is that the history of domestic violence that is generally experienced is not only one type, but multiple or even a pregnant woman has experienced two or more types of violence by her husband [8, 10, 17, 19]. The results obtained are that there are 2 pregnant women with a history of experiencing physical and sexual violence at the same time, there is one pregnant woman who is a victim of physical, emotional and economic violence, one person experiences sexual and social violence. As many as two pregnant women who admitted to experiencing physical and sexual violence at the same time in their lifetime, two pregnant women experienced a history of sexual and emotional violence, and the most pregnant women experienced economic violence. Thus, women at most experience more than one form of violence in their lives, especially physical, sexual and emotional violence, in addition to economic violence . Women experience the most economic violence when compared to other forms of violence, such as sexual, physical, social, and emotional or psychological violence. In the picture below, an overlapping illustration of violence experienced by pregnant women in the last 12 months is shown (Figure 1).
The results of the study in India found that the most common type of violence reported was physical violence. The most common cause of domestic violence reported in our study was financial problems followed by influence under alcohol . As many as 60% of women who reported having been threatened with violence in Uganda, but few reported acts of violence that had been experienced. The previous year, and very few reported acts of violence . Thus, DV events experienced by women are in the form of more than one form of violence or multiple acts. This condition certainly has a bad impact on the health and welfare of women.
Husbands who were perpetrators of violence, when asked the reasons for beatings or engaging in sexual coercion, said that women must be educated properly by their husbands. Women must not violate the restrictions given by their husbands, as well as actions taken by their husbands as normal things to do. The explanation of this behavior is based on the WHO’s ecological model framework theory. There are four levels that trigger it, namely: the individual level, personal relationships, community and societal factors. From the individual characteristics in Bali that are related to abusive behavior, they are men with low education level, low income, have a habit of drinking alcohol, live in the periphery or rural areas. Community and societal factors that trigger violence by men are patriarchal culture, family upbringing, and the existence of values that view violence is commonly committed by men. There have been no clear sanctions for perpetrators of violence. In this case, results from in-depth interviews with traditional leaders in Bali, it is found that there needs to be customary rules or “Awig-awig” for perpetrators of violence. Despite the fact, it takes a lot of hard work and a lot of money to make customary rules.
3.5 Impact of domestic violence experience to women and babies wellbeing
Pregnant women in Bali experience several forms of physical violence by their husbands, for example: beatings on the stomach, breasts and genitals which have a direct negative impact on their pregnancy . In other words, the act of DV especially physical violence against pregnant women, increases the negative risk during pregnancy by 2 times [3, 4, 8, 17, 19, 25, 32, 33, 34, 35, 36]. The main health or psychological problems faced by pregnant women especially poor appetite, easily tired/feeling tired, frequent headaches, sleep disturbances and tired/tired all the time, had thought of committing suicide and thought of ending life . That acute stress levels are related to the incidence of cardiovascular disease, hypertension, gastrointestinal disorders, chronic pain and diabetes. Stress during pregnancy is associated with the birth of low birth weight babies (LBW) as a result of increased cortisol levels which stimulate constriction of blood vessels that restrict blood flow to the uterus. Thus, the hypothalamic–pituitary-and adrenal response as a trigger or trigger of preterm labor and preterm birth, through the contraction of the smooth muscle tissue in the uterus . Exposure of prenatal stress can have negative long-lasting impacts on health and disease susceptibility [4, 6, 7, 8, 19, 23, 26, 27, 34, 35, 36, 37]. Acts of violence or abuse by an intimate partner can cause physical trauma, psychological trauma, and fear of women who are victims [38, 39, 40]. Physical trauma is experienced from mild to severe, which affects the disability and death of women. Physical disorders or trauma affect the mental health conditions of victims/women in the form of post-traumatic stress disorder, anxiety, depression, eating disorders and suicidal thoughts . Sub-ordination in Bali has an impact on decision making in choosing the place of delivery, who is the delivery assistant and other preparations when facing pathological conditions and/or emergencies during pregnancy and childbirth. Decision making is mostly determined by husbands and in-laws. The wife can only be the recipient of this decision. This has an impact on delays in referral efforts and acts to save mothers and their babies, so that the morbidity and mortality rates for mothers and babies are still high.
Domestic violence is a global issue that requires extraordinary efforts from various components to overcome it. DV problem solving starts from individual, family, group and community lines. Broad-scale research in the field of gender issues, especially domestic violence, is expected to be able to open up insights and commitments from policy holders related to gender. Women who have been physically or sexually abused by their partners report higher rates of a number of important health problems . According to The Legal Aid Foundation of the Indonesian Women’s Association for Justice in 2020, found that strong patriarchal norms and conservative religious values that put men above women. Including the patriarchal culture in Hindu society in Bali which indirectly perpetuates acts of violence against women both in the domestic and public sphere.
3.6 Policies and roles of midwives to eliminate incidents of violence against women
The Indonesian government issued a law related to the elimination of domestic violence in 2004, which was followed by a 2009 Minister of Health decree on Guidelines for the Management of Integrated Services for Victims of Violence against Women and Children in Hospitals. The personnel or officers who have responsibility and competence in providing services to victims of violence are: 1) a forensic specialist/psychiatrist/other specialist doctor; 2) trained general practitioners; 3) midwife/nurse; 4) psychologist; 5) social workers; and 6) other health workers in the form of administrative personnel and medical records.
Midwives have a strategic role in early detection and provide assistance to pregnant women victims of violence. Midwives are health professionals who are at the forefront of maternal and child health services. Since the last decade, the issue of violence against women has been rolled out and has become a national issue. The midwife has a strategic role because pregnant women are the first to be contacted by a pregnant woman in a health care facility. Midwives with the motto as friends of women will be able to dig up more data and early detection of these incidents of violence. Screening is the right step for health workers. Screening is carried out with adequate instruments and in accordance with the local socio-culture .
Midwives in Bali have been given training several times regarding early detection of incidents of violence against pregnant women and referral measures, as part of integrated services in basic health care facilities. The problem is that the training activities have not been evenly distributed to all midwives on duty, so that the problem of violence against women, especially pregnant women, has not been optimally resolved. The effort of midwifery education institutions is to include the topic of gender issues and violence against women in the midwifery education curriculum, especially reproductive health. Introducing midwife students is a strategic effort as a provision in providing services in their place of duty.
Researchers in the field of reproductive health and maternal and child health have attempted to carry out various studies related to gender issues, especially the incidence of violence against women and disseminate the results of the study widely. The main obstacle in accelerating the reduction in the incidence of violence against women, especially pregnant women, is that there is no clear and sustainable policy from policy makers regarding the elimination of incidents of violence against women.
In the case in Bali, women victims of domestic violence were given explanations and were guided in efforts to save themselves and seek help when they were in a situation that threatened their safety. An important and simple trick is the most appropriate step in addition to empowering community organizations in customary villages.
4. Summary and recommendation
Balinese women are born to carry out their duties and responsibilities to become obedient, loyal and devoted women to God, ancestors, in-laws, husbands, children and their parents. That is the full responsibility of Balinese women in the family, even though sacrifice has never been properly interpreted.
Violence against women is a serious violation of human rights, because it has a negative impact on the health and welfare of women. Violence against women undermines the dignity of women as human beings. The cause of domestic violence incidents is influenced by individual, family, community and societal factors. The ecological framework of the model can explain in detail the influence of these factors on the incidence of DV. Economic abuse and emotional/psychological abuse are the most common forms of DV experienced by pregnant women in Bali. The type of abuse experienced is more of multiple abuse.
There are various reasons why health services have a critical role in helping women victims of violence. Women victims of DV will use health facilities more often, and health workers are the professionals who first make contact with victims. The most common and the most severe form of violence against women, can occur in a variety of settings. The incidence of DV is taboo to tell, in fact women are often blamed for various incidents of sexual violence they have experienced.
The role of midwives is very strategic in preventing and early detection of incidents of violence against women, especially during pregnancy, because it has a negative impact on the health and well-being of pregnant women and their fetuses. Cooperation across sectors, programs and laws and regulations that clearly regulate efforts to eliminate incidents of violence against women is urgently needed. There must be synergy between policy makers, community or traditional leaders, health care institutions and midwifery education institutions in the effort to eliminate acts of violence against women.
The author would like to thank: Head of the Health Research and Development Agency, Center for Humanities, Health Policy and Community Empowerment, Surabaya; Prof. Anom Umbara, from Udayana University as research consultant; and Prof. dr. M. Hakimi.
Conflict of interest
There was no conflict of interest in the research and preparation of this report.
Thanks to the data analysis officers, enumerators, Mr. Akto Adi, Mr. Tri Wahyu Yuliono and respondents who played a big role in this study.