As researchers and actors in the maternal and child health space, Sevil Hakimi and Laura Neenan came together from two seemingly different parts of the world to reflect here on the state of women’s health in their countries relevant to domestic violence and mental status during COVID-19 pandemic
By Sevil Hakimi
RM. PhD. Associate Professor of maternal and newborn health. Tabriz University of Medical Science. Tabriz. Iran. hakimis@tbzmed.ac.ir
and Laura Neenan
BSc. MA. Teaching Assistant at School of Education. University of Limerick. Limerick. Ireland laura.neenan@ul.ie
Shadow Pandemic: Women’s Health in the Time of COVID-19
The COVID-19 pandemic continues to overwhelm health systems both globally and locally in complex and nuanced ways. The fallout of the pandemic has greatly affected women and children in both developed and developing countries, including increases in domestic violence, child marriages, and rising mental health burden. COVID 19 has manifested itself in pervasive ways that have taken us back around 20 years on important progress that was being made across many fronts.
As researchers and actors in the maternal and child health space, we – Sevil Hakimi and Laura Neenan – came together from two seemingly different parts of the world to reflect on the state of women and children’s health in our countries, and the role of COVID-19 in shaping outcomes. Sevil is an associate professor of maternal and newborn health in Tabriz University of Medical Science in Iran, and Laura is a teaching assistant and former post graduate researcher in the area of suicide prevention at the University of Limerick in Ireland. Our countries could not be more different across cultures, income-levels, geopolitical situations, as well as health system capacities, yet we find similarities in issues close to our heart, around women and children’s health within our countries. While there are many more important themes within the broader topic of women and children’s health that are worthy of our collective attention, we will be focusing on domestic violence and Y here, given our own experiences and focused interests.
Domestic violence as a hidden issue in Ireland and Iran
Domestic violence is a critical issue that has a pervasive effect on the individual, and therefore the development of a nation at large. It also remains a largely ‘hidden issue’ given that women are often reluctant or unable to report cases due to a myriad of reasons ranging from cultural or social stigma, to lack of policy infrastructure, distrust of officials, or limited knowledge around pathways for seeking additional support. Following COVID-19 protective measures and “stay at home” policies, domestic violence rates increased against women and children around the world. While there is no clear data comparing domestic violence against women between developed and developing countries, evidence suggests that in both Ireland and Iran, domestic violence has risen since the outbreak of COVID-19.
In Iran, the dominant cultural view states that an Iranian woman enter her husband’s house in a white wedding dress, and can only leave in the same white dress. These social and cultural norms can often lead to Iranian women enduring violence and not reporting cases due to related stigma. During the first and second wave of the pandemic and during times of lockdown, evidence and studies showed that the prevalence of experienced domestic violence among Iranian women has increased.
Domestic violence against women in Ireland, like in most other countries, is something not openly discussed. It brings with it feelings of shame with impact on women’s ability to seek help for their situation. In contrast to Iran divorce is easier in Ireland. The prohibition of divorce was removed from the Constitution and was signed into law in 1996. Historically, the Catholic Church had a strong influence on Irish society, and its views on divorce, as well as the use of contraceptives greatly influenced women’s ability to seek help for domestic violence.
In Ireland evidence suggests that domestic violence has risen since the outbreak of COVID-19. There was a 6 per cent increase in criminal charges for breaches of Domestic Violence Act Orders in 2021 based on 2020 figures. According to Safe Ireland (2021), when the country was at the height of its second Level 5 lockdown, more than 2,180 women and 602 children availed of support from a domestic violence service.
We need urgent action, increased political and social will, and a commitment to sound policy and resource/information infrastructure to address the rising rates of domestic violence in both Ireland and Iran, as well as other countries around the world. It is promising to see Ireland’s recent approach to help protect women against domestic violence, in passing legislation making coercive control a criminal offense.
Burnout among health care workers and the rising mental health burden among women
Burnout has a substantial impact on not only staff, most which are women, but also on the health care system itself. Iran and Ireland are different according to health system infrastructure and human resources. Iran is under serious economic sanction. Sanction leads to drug and medical devices shortage in Iran. Health workforce shortage, maldistribution and migration of health workforce are among the top problems in the Iranian health system, and these have been exacerbated and with more serious consequences since the nuclear sanctions. Due to a lack of appropriate budgetary resources, the government has not been able to invest in growing, nurturing or developing a new workforce, and the stress of the health system falls on the pre-existing (and burnout) few. The World Bank estimated in 2018, that Iran had approximately 2.1 nurses and midwives per 1000 population. In contrast, the United States had 15.7, Ireland had 13.0, and Canada had 11.8. Even among the Arab World, Iran fared poorly, with the United Arab Emirates having 5.7 nurses and midwives per 1000 population, Saudi Arabia with 5.8, and Kuwait with 7.4. Studies looking at the context in Iran have shown significant burnout and emotional exhaustion among health care providers, which especially affect women who make up.
Ireland, on the other hand, has a strong health system, with an approximately adequate health workforce (13 nurses and midwives per 1000 population). However evidence shows that both health systems suffer from workforce burnout during pandemic. There is limited literature addressing burnout from an Irish context during the COVID-19 pandemic, however one such study reported psychological distress to be prevalent among health care workers. It seems that, high workload, fear, prolonged involvement with COVID-19 and hopelessness are among the predisposing factors for health workforce burnout. Burnout results in increased absenteeism, increased medical errors and as a consequence negatively impacts patient care.
Both countries have reported increases in rates of anxiety and depression among women. Anxiety and depression among women have been reported to be higher than in men, although factors like social stigma and gender norms may affect reporting. This is of particular significance when looking at the impact of mental health disorders during pregnancy. The treatment of depression and anxiety during pregnancy and postpartum period is critical for the health of mother and baby. Interestingly, in both Iran and Ireland data shows a decrease in preterm birth rates, as well low birth weights during the first and second wave of pandemic. This may be due to improved hygiene practices, changes in work environment and lifestyle. It’s estimated that a number of health promoting behaviors have been disrupted completely or partially within the lock down period. They include regular exercises in indoor places, routine medical follow- up, annual screening tests like mammography, pap smear, blood tests etc. Fear of getting infections, as well as lockdown policies are among the top cited causes of postponing such healthy behaviors. These further affect consequences among women, and lead to negative impacts on their health and well-being.
The impact of COVID-19 is universal, affecting both developed and developing countries. Health system resilience is therefore a very crucial factor in the level of involvement between countries. Regardless of the level of development in each country, women are among the most vulnerable population. It is, therefore, imperative that governments and the global society consider appropriate strategies in order to mitigate the risks and results of the COVID-19 pandemic on vulnerable populations.
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Dr. Sevil Hakimi is associate professor of Midwifery in Iran. With more than 15 years, she is experienced in clinical working and volunteer working in the refugee camps as well as in the research. Since 2013 she has worked as an academic member in the department of midwifery in Tabriz University of Medical Science. She is teaching undergraduate and postgraduate students. She has been supervisor for more than 30 master and doctorate thesis and has published several papers in peer review journals. She is editorial board member of European Journal of Midwifery. Her main research areas are in maternal and preterm newborns` health and health system strengthening on maternal care. Dr. Hakimi has served as consultant for WHO, UNICEF and was visiting professor in Turkey for 4 years. By Dr. Hakimi recently on PEAH: Beyond the Waives: Indirect Effects of Covid-19 on Mothers in Low and Middle-Income Countries
Laura Neenan BSc, MA; is university tutor in the School of Education at the University of Limerick, where she teaches on modules that focus on the psychology of education with a specific focus on inclusivity. She serves as a member of the European region of the International Working Group for Health Systems Strengthening (IWG) and her research interests include suicide prevention, health literacy and mental health promotion. She is a registered nurse and a SafeTALK trainer, whereby she delivers suicide prevention training workshops to a range of community groups on behalf of the National Office for Suicide Prevention.