Currently there is limited data on deaths due to gender-based violence (GBV). Neither medical certification of cause of death (MCCOD) forms nor verbal autopsy guidance explicitly capture information about GBV. Capturing GBV-related deaths requires some inference and investigation, which is resource intensive and not routinely done in most countries.
MCCOD
The international MCCOD form captures whether a death was due to an accident, assault, war, or intentional self-harm, among other manners of death. The underlying context and information about possible perpetrators which could help classify the cause as GBV is not currently captured. Medico-legal death investigations (MLDI) are one way to do this, but this requires collaboration with the legal system. We know GBV is vastly underreported within legal systems for many reasons, including fear of retaliation of the reporting party.
The MCCOD typically only specifies natural/non-natural as classifications for causes of death. Intentionality is only recorded for some external causes and international coding norms require that where intentionality is not recorded the death defaults to unintentional.
This image shows the classification of injury death in South Africa. You’ll notice on the left that 64% of deaths fall into the Other, Unintentional category. Global Burden of Disease uses data on the left and then “models it” based on your-guess-is-as-good-as-mine…
From the pie diagrams you can see overall female homicide/femicide but in order to investigate femicide and gender-based violence, we need to know more. We need to know who killed the women and in what context, as the risk factors for being killed by an intimate partner are different than being killed by a stranger.
VERBAL AUTOPSIES
Globally, most deaths occur at home or other locations outside of health facilities, and often go unreported. This is particularly the case in countries with underdeveloped and under resourced civil registration and vital statistics (CRVS) systems. In many countries, people who die outside of health facilities are also experiencing structural inequalities and have poorer access.
Verbal autopsy (VA) is one method of capturing information from family members or next of kin to estimate the probable causes of deaths that occur at home and other places outside of health facilities. Verbal autopsies identify whether a death was due to suicide or whether an injury or accident led to the death. If an injury or accident, verbal autopsies aim to identify whether the death was caused by a firearm, stabbing/cutting, blunt force, or electrocution. Whether these modes of injury were intentional is not captured explicitly, nor whether an intentional injury was one that can be classified as GBV. Verbal autopsies could capture information to classify deaths as due to GBV in the narrative description but may require some specific questioning or prompting. There could also be shame and embarrassment from the surviving family members if GBV occurred, as well as potential fear of the perpetrator.
Verbal autopsies could capture information to classify deaths as due to GBV in the narrative description but may require some specific questioning or prompting. For example, VA interviewers might consider adding a few brief sentences or an additional checklist item to indicate whether the death was caused by an injury that was or could be linked to gender-based violence. Language around this could be tailored to the regional or national context, and help interviewers identify whether injuries were due to physical violence inflicted due to gender norms or relations (e.g., domestic abuse, retaliation for culturally taboo sexual behavior, etc.) or injuries that could have resulted from female genital cutting, sexual abuse, or rape.
THE KEY TO CAPTURING GBV IN MORTALITY STATISTICS IS CROSS REFERENCING DATA
@Nidhi Chaudhary and her team are currently conducting a study with the Forensic department of a medical college in Mumbai, India looking at post-mortem case records of the last 5 years for women and girls who have died of unnatural causes to identify deaths associated with GBV. Identification is difficult as it is not clearly captured in these MLC records. They are going through history sheets, autopsy findings and looking for cases where the two do not corroborate.
@Naeemah Abrahams has been doing femicide research in South Africa and uses both mortuary data and police data, as they will never be able to get perpetrator data from the mortuary data alone as it is not the forensic pathologist’s domain. Forensic pathologists conduct an autopsy and provide information on probable cause of death. they can provide information such as evidence of rape and then, Naeemah’s group can identify deaths as femicides. It therefore does not make sense to only collect mortuary-level data in South Africa.Fatima Marinho at Vital Strategies has been working on this issue in Brazil. Dr. Marinho states, “Building strong surveillance systems is the result of a careful analysis of mortality data, disaggregating it by gender and investigating the deaths of women, especially women of reproductive age (10-49 years old) who die.” The data needs to come from multiple sources, including:
- Violence Surveillance System
- Mortality System
- Mortality System
- Police Investigation Data
@Julia Ahmed works in Bangladesh, where the key data sources for identifying domestic violence cases are the One Stop crisis centers (admitted cases), Hotline numbers, and DV national surveys (the last one in 2015); and piecemeal research. In Bangladesh, there is a multisectoral program under the Ministry of Women’s Affairs to address domestic violence issues base on Bangladesh’s Domestic Violence Act of 2010. In this approach, health sector response, police investigation, and legal measures are key interventions. Of course, these are the cases when domestic violence or gender-based violence is already indicated.
It’s really quite complicated to get all these systems talking to each other – and to access all the data available in order to determine actual cause of death by gender-based violence. Taking a deep dive into the data to understand the context and motivating cause of intentional deaths is what will help us identify GBV-related deaths.And when we work with gender-based violence, we also need to have resources are the ready, because there are always survivors in the midst. Here are some survivor resources to use in your work:
Global resources:Hot Peach Pages: International Directory of Domestic Violence Agencies
www.hotpeachpages.net
Global Modern Slavery Directory: Anti-trafficking organizations in over 145 countries www.globalmodernslavery.org
Africa Region:
https://shebafeminine.co.za/sex/5-organisations-fighting-gender-based-violence-in-south-africa/
https://www.globalcitizen.org/en/content/organisations-fighting-sexual-violence-nigeria/I
GBV support center in Kenya: https://gvrc.or.ke/facts-about-gbv/
South Asia:
Home – Sakhi for South Asian Women (36 kB)
ADDITIONAL READINGS
Verbal autopsies to increase gender equity in mortality statistics
https://genderhealthdata.org/resource/verbal-autopsies-to-increase-gender-equity-in-mortality-statistics/
How Gender Norms affect Completeness of CRVS Death Registries
https://genderhealthdata.org/resource/how-gender-norms-affect-completeness-of-crvs-death-registries/
Femicide Brief Updated 20 Oct 2022.pdf (South Africa)
Fatima Marinho presentation, Vital Strategies, Capturing Accurate Numbers for GBV in Brazil Slides:
https://docs.google.com/presentation/d/1gaADKkMU8AERLBVI8TwCH6YlYJ4HCMfZAHoQa09rPW4/edit?usp=share_link
Video: Start at 32.03
Using Health Data to Develop Gender-Responsive Policies
