Reproductive Rights: An Unacknowledged Casualty of Conflict in Sri Lanka

Reproductive Rights :
An Unacknowledged Casualty of
Conflict in Sri Lanka
Sepali Kottegoda
Kumudini Samuel
Sarala Emmanuel
The Women and Media Collective

With Support of the Ford Foundation, New Delhi
2015
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Reproductive Rights: An Unacknowledged Casualty of Conflict

The Women and Media Collective
ISBN 978-955-1770-22-8
First Print - January 2015
Edited by
Sepali Kottegoda
Kumudini Samuel
Sarala Emmanuel
Special Thanks
Sunila Abeysekera
Roshmi Goswami
Cover Illustration
Ninel Fernando
Page layout
Velayudan Jayachithra
Printed by
Globe Printing Works
Supported by
Ford Foundation, New Delhi
Out thanks for technical assistance to Mr. G. Colombage, NIBM for tabulation of
data and Mr. Chandima Bandara for graphics preparing the graphics
Published by
Women and Media Collective
56/1, Sarasavi Lane, Castle Street, Colombo 8, Sri Lanka.

Email:wmcsrilanka@gmail.com
Web:http://www.womenandmedia.org
Facebook:http://www.facebook.com/womenandmediacollective
Twitter:http://twitter.com/womenandmedia
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Content
Page
1.0 Introduction 11
1.1Exploring a Reproductive Rights Framework..................................... 13
1.2 Recognition of Conflict Impact on Health Research................. 15
1.3 National Health Policy and Programmes...................................... 17
1.4 Reproductive Health in Conflict and Displacement Settings..... 22
2.0 The Women and Media Research Study........................................ 25
2.1 Scope and Methodology........................................................................ 25
2.1.1 Ethnic Distribution of Interviewees.......................................... 27
2.1.2 Age Distribution of Interviewees.............................................. 28
2.1.3 Level of Education of Interviewees.......................................... 29
2.1.4 Marital Status of Interviewees.................................................... 30
2.2 Life Cycle Approach to Reproductive Health and Rights................ 30
2.2.1 Age at Puberty................................................................................ 31
2.2.2 Age at Marriage.............................................................................. 31
2.2.3 Age at First Live Birth................................................................. 34
2.2.4 Knowledge of Contraception.................................................... 35
2.2.5 Experience of Miscarriage........................................................... 36
2.2.6 Age at First Miscarriage................................................................ 37
2.2.7 Age at Menopause......................................................................... 38
2.2.8 Location of Childbirth.................................................................. 40
2.2.9 Traditional Midwives..................................................................... 42
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iii
2.3 Reproductive Health and Gender-based Violence............................ 43

2.3.1 Domestic Violence........................................................................ 43
2.3.2 Forced Sexual Intercourse in Marriage...................................... 46
2.4. Reproductive Health During Time of Active Conflict................... 48
2.4.1 Childbirth During Period of Active Conflict............................ 49
2.5. Social Exclusion and Structural Barriers to Accessing Services..... 50
2.5.1. Reproductive Choice as Freedom............................................. 53
2.5.2. Informed Choice.......................................................................... 55
2.5.3 Abortion......................................................................................... 57
2.6 Impact of the Tsunami Disaster on Womens Reproductive
Health and Rights................................................................................... 58
2.7 The Research Findings........................................................................... 62
2.8 Conclusions.............................................................................................. 67
3.0 District Level Findings
3.1 Puttalam District.............................................................................. 74
3.2 Mannar District................................................................................ 87
3.3 Polonnaruwa District Border Villages....................................... 99
3.4 Batticaloa District.......................................................................... 113
3.5 Jaffna District................................................................................. 129
3.6 Ampara District............................................................................. 143
Annexure 1.
Reproductive Health Concerns and Related Violence Against
Women Questionnaire: First Phase........................................................... 152
Annexure 2.
Women Questionnaire: Second Phase .................................................... 158
iv
4
List of Tables
1. Selected Health Status Indicators for the Conflict -

Affected North and East, and Sri Lanka .......................................... 23
2. District-wise Ethnic Distribution of Interviewees........................... 28
3. Age Distribution of Respondents........................................................ 28
4. Level of Education by District............................................................ 29
5. Marital Status of Interviewees by District......................................... 30
5. Age at Puberty ........................................................................................31
7. Age at Marriage by District................................................................... 32
8. Age at First Live Birth by District........................................................ 34
9. Knowledge of Contraception............................................................... 36
10. Experience of Miscarriage in Pregnancy............................................. 37
11. Age at First Miscarriage.......................................................................... 38
12. Age at Menopause.................................................................................... 39
13. Location of Childbirth by Number of Children
Born to Interviewees............................................................................... 41
15. Domestic Violence................................................................................... 44
16. Number of Childbirths Before and During Time of
Active Conflict and After the CFA...................................................... 51
v5
Foreword
he international conferences of the 90s created unprecedented

focus on rights. The Cairo and Beijing conferences in particular
enabled more progressive discourses on womens health and rights and
contributed significantly towards bringing about a recognition of sexual
and reproductive rights as part of the universal human rights discourse.
By the late 90s however the euphoria around these gains was over and
one began seeing a gradual dilution of the rights language and of rights
work. Use of a human rights framework for implementing programs in
Sexuality and Reproductive Health was often rhetorical for both the state
as well as civil society groups and many organizations began losing their
political and social justice sharpness by shifting into project implementation
mode drawn in by the considerable and ready resources made available by
both funders and states for work on specific SRH issues.
Contentious and sensitive issues need to be constantly supported and

sustained by strong movements and institutions that have both a wide
and more nuanced perspective of human rights as well as the capacity
to use both national and international human rights and standards to
monitor national policies and for ongoing advocacy. The availability
of support only for specific funder prioritized SRH issues itself drove
home the point that getting these rights recognized however was only
one baby step in the direction of making these rights real for women and
that there were huge challenges to secure these rights. It was clear then
that these rights claims would therefore have to be enabled and sustained
versus just being recognized and talked about, and strong and sustainable
womens rights institutions would have to be built that would constantly
address emerging challenges in securing any aspect of womens rights.
The complexity of the debates that ensued around these rights during
6
vi
the conferences also gave an indication of the kind of challenges one

would have to encounter to claim these rights. The need for funders and
programmers to engage with and strengthen and support the womens
movement which had in the first place brought these rights to the
negotiating table was an imperative.
At that point of time the Ford Foundation which had a clearer and more
committed South Asian presence than now, also played an important
role as a progressive funder on womens rights in the region. The New
Delhi offices SRH programme made a critical shift into a human rights
programme and moved the focus from a womens health-centered one
to that of social justice that necessarily questions underlying inequalities
and discrimination and, affirms the fundamental value of human agency.
Among others two related questions that repeatedly surfaced then is
how can the more contentious sexual and reproductive rights be secured
when the overall rights of women are constantly eroded and how can
a woman claim these rights in a context where the overall rights of the
community itself is threatened as in a context of armed conflict based
on ethnic identity, class or religious minority divides. Strategies used to
enable the shift therefore included: investing in long term institutional
support to build strong womens human rights organizations in the South
Asia region which would be pillars of expertise and advocacy; supporting
the womens movement to address the mosaic of interconnected socioeconomic-cultural factors which keep changing and intersecting differently
at different moments of time to obstruct the realization of womens
rights; and surfacing and addressing the socio political underpinnings
and the intersection of caste, class, ethnicity and religious identities of
violence in contested and armed conflict areas etc
The Women and Media Collective has been an invaluable partner of the
Ford Foundation in that journey of promoting and securing womens
human rights and a key partner on work and analyses related to women
in armed conflict situations. WMCs research report: Reproductive Health
Concerns and Related Violence against Women in Conflict-Affected Areas in Sri
Lanka: Preliminary Research Findings while addressing some aspects of
the second question elaborates the various challenges of protecting and
addressing issues of reproductive health and rights in a context of armed
vii7
conflict underpinned by deep ethnic divides, marginalization and rampant

discrimination against certain communities of people. Organizations with
strong feminist politics and nuanced and comprehensive understanding
of womens human rights like WMC are indispensable in the struggle for
gender justice in situations of armed conflict. WMC has kept the flag
flying high on womens rights and democracy in the highly volatile and
fragile situation of Sri Lanka. At one point of time when hostilities in
the already Tsunami affected North East and East resumed, the peace
process collapsed and indiscriminate killing of civilians exacerbated,
womens rights work faced huge challenges. WMC managed to maintain
the balance of constantly addressing human rights violations and at the
same time not relenting on specific womens rights like reproductive
rights of Internally Displaced Peoples (IDPs) and other conflict affected
women, sexual rights and rights of sexual minorities, the Domestic
Violence Bill, the extreme vulnerability and need for protection of
women human rights defenders. This research is both deeply grounded
in realities from the field and strongly informed by feminist politics and
is an invaluable addition to the very scarce pool of resources available on
armed conflict and womens reproductive health and rights in South Asia.
Armed conflict, whether a violent form of hostility or a low intensity
protracted conflict deeply affects the entire community but the way
men and women are affected are different because of the way womens
roles and images are socially constructed. Many armed conflicts across
the globe and, primarily those related to or arising out of questions of
marginalization, discrimination and exploitation stem from a context of
entrenched inequalities where certain sections of people, are not just
exploited but socially excluded and lack access to even the minimum
socio economic needs like food water, health, education, and decent
livelihood opportunities. The deeper the entrenched inequalities and social
exclusion in a pre conflict society against certain categories the greater
the impact of conflict on these excluded categories. Impact can be said
to be directly proportional to vulnerability of the group or collectivity
and, reports from across the world have brought out the stark gender
inequalities. They point to the endemic nature of violations of womens
human rights with the impact being hardest on excluded categories of
women like poor, young, indigenous, religious and ethnic minorities and
viii
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so on. And each time newer categories of vulnerable women emerge as a

direct consequence of the conflict - not just poor indigenous women but
poor indigenous women who have been rendered homeless and internally
displaced or have been subjected to gross human rights violations like
rape and sexual slavery, or women human rights defenders who raise
contentious issues of womens rights violations and demand redress or
women combatants who have participated in the conflict by choice or
forcibly conscripted .
Reproductive Health Concerns and Related Violence against Women in ConflictAffected Areas in Sri Lanka: Preliminary Research Findings has managed to
bring out a range of excluded categories of vulnerable women while
focusing on the health implications of protracted conflict on their lives and
in their access to entitlements. The implications are many and inextricably
intertwined with the womens status and identities. Despite the fact that
Sri Lanka has better health provisions than the rest of South Asia, the
study does point to the fact there were disparities in the different districts
peopled by different ethnic communities and the conflict has exacerbated
the disparities. Thus some districts show a complete breakdown of the
public health delivery systems, or given the disarray that everything due
to the years of armed conflict, womens reproductive health are either
disregarded or not prioritized by the medical administration which focuses
on providing the minimal public health services rather than special needs.
High levels of insecurity on the roads, lack of transport or lack of the
means to take transport which have life threatening consequences for
women in immediate need of reproductive health services are other issues
that are brought out. In a contested situation there are other implications
of womens lack of reproductive choices and options as well. Sexual
activity for many girls during periods of armed conflicts may increase
because of forced or under aged marriages, prostitution or policies of
systematic rape and abuse, or even voluntary positions of offering formal
or informal sexual services. This increased activity often results in early
pregnancy or increase in STIs. The study shows that there is a total lack
of understanding of these aspects as evidenced by poor availability of
contraceptives or contraceptive choices, lack of emergency contraceptive
or abortion services particularly for victims of rape and incest and high
maternal mortality.
ix9
In situations of armed conflict assertion of ethnicity and identities is often

over exaggerated and patriarchal and fundamentalist values and ideologies
are reinforced. While women are expected to uphold without questioning,
both the negative and positive aspects of their native cultures, men have
the choice of being unbound and unregulated by even the positive values
and belief systems of their indigenous cultures. Looking at the situation
through a feminist lens the study is interspersed with examples of how
patriarchy uses situations of armed conflict to perpetuate controls and
gender subjugation whether it be bigamous men absconding to the active
conflict zone to escape responsibilities, men using war related trauma
to justify marital rape and incest or, be it on questions of ethnicity and
the need to preserve a minority identity where women are forced into
pregnancies to increase numbers. By using a rights based approach
the research highlights the continuum of discrimination and gender
inequalities that get exacerbated in general and for certain excluded
communities in particular and calls for a post conflict reconstruction
where notions of justice and rights are foundational. Finally while
focusing succinctly on the various aspects of reproductive health and
rights the study surfaces the fundamental questions that must basically
inform all efforts at ensuring access which are : who is most deprived,
what is the nature of the deprivation and the larger and more structural
question of why this deprivation which has within it the question: who
drives the deprivation ?
With these thought I am happy to introduce these research findings and
congratulate the Women and Media Collective for bringing out these
important findings which I hope will be picked up by policy makers.
Roshmi Goswami
ex Programme Officer, Ford Foundation

ex Unit Head, Women, Peace and Security for South Asia, UN Women.
10
x
1. Introduction
his study analyses the experiences of women living in areas of Sri

Lanka that were affected by armed conflict for more than two decades.
It is based on research was carried out in the districts of Jaffna (North),
Mannar and Puttalam (Northwest), the border villages in Polonnaruwa
(North-Central), and Batticaloa and Ampara (East) between the years of
2003 and 2005.1 During the early part of this period there was a ceasefire
in place between the Government of Sri Lanka (GOSL)and the Liberation
Tigers of Tamil Eelam (LTTE) which made it possible for interviews to
be carried out in most of the conflict affected districts covered in the
study. The December 2004 Indian Ocean tsunami affected the eastern
coast of the country, affecting Batticaloa and Ampara districts particularly,
bringing much hardship to a population already affected by the conflict.
The study is being published a decade after the research was completed
given the relevance of the findings especially in the context in which the
ending of the war in 2009 has brought many of these issues once more
to the forefront of the development agenda of the country.
The study draws on womens shared experiences of accessing health
services, as well as the familial and social relationships that have mediated
aspects of their well-being related to reproductive health. The objectives
of this book are twofold. On the one hand, it attempts to contribute
to the knowledge base on reproductive health in Sri Lanka by bringing
in the voices of women to policy-making and academic discussions and
interventions. On the other, this book attempts to make a strong argument
that the health of women, especially the reproductive health of women
living in conflict situations, must be framed within a rights discourse.
1. An abbreviated version of the study was published as an article in Reproductive Health Matters,
Vol 16, Issue 31. pp 75-82, Published by Elsevier Inc 2008.
11
A human rights framework provides a foundation to address issues of

social justice (and injustice) in development. It also allows the shifting of
priorities to benefit the most deprived and excluded groups, especially
those who have been marginalized and discriminated against (UNDP
2000).2 Global development discourses have increasingly articulated
development as the right to both entitlements and freedoms, to be enjoyed
by every human being. Through this, the space has also been created
within national policy circles to argue for womens reproductive health
concerns through a rights framework. As the International Covenant on
Economic, Social and Cultural Rights (ICESCR), to which Sri Lanka is a
signatory, states:
The right to health is not to be understood as a right to
be healthy. The right to health contains both freedoms and
entitlements. The freedoms include the right to control ones
health and body, including sexual and reproductive freedom,
and the right to be free from interference, such as the right
to be free from torture, non-consensual medical treatment
and experimentation. By contrast, the entitlements include
the right to a system of health protection which provides
equality of opportunity for people to enjoy the highest
attainable level of health. (ICESCR, General Comment No.
14, para 8)
The rich experiences of women documented through this research
exemplify why reproductive health is not merely a health issue to be
solved through better health services. Their stories speak of structural
factors that impede their well-being. These structural barriers stem from
socio-cultural practices and values in their homes and communities, as
well as from structural barriers due to their experiences as displaced
women or women living through armed conflict and women grappling
with the realities of living in periods of transition, where the absence of
war has not necessarily resulted in peace or the positive transformations
envisaged in a time of peace with justice. As the above quote elaborates,
a rights framework provides the basis on which arguments can be made
2 UNDP (2000). Overview: Human Rights and Human Development for Freedom and
Solidarity, in Human Development Report 2000, Oxford and New York: Oxford University Press.
12
both in terms of freedoms and entitlements for women. A rights framework

highlights concerns of social exclusion where vulnerable communities
and groups fall through the gaps in macro state policies. Reproductive
health then becomes not only an economic or social right, but a political
right based on ones entitlements through citizenship that does not
discriminate on the basis of ethnicity, language or geographical location.
A Rights Framework also bring into focus the politics of citizenship and
entitlements in the context of specific discrimination and marginalisation
on the basis of ethnicity, language and geographical location. A situation
of a lack of equal citizenship status is now clearly recognised as a key
factor for the evolution of the ethnic conflict in Sri Lanka. The majority
of persons affected by the conflict in the districts included in this research
were from the minority Tamil and Muslim communities as well as from
the majority Sinhala community. These districts had differential outreach
of government services compared the rest of the country, especially as a
result of the war. The research findings offer a pioneering record of the
voices of women who struggled to survive in a context of hardship and
insecurity.
1.1 Exploring a Reproductive Rights Framework

The reproductive rights framework brings into focus the issue of the
right to health, which includes the principles of availability, accesability,
acceptability and quality of care in relation to womens and mens
reproductive health3. For instance, issues such as making available a range
of contraceptive choices, and the provision of full information on different
methods available and their effectiveness and side effects, become critical
in the provision of reproductive healthcare. The quality of care issue
also calls for a non-biased attitude from those professionals in the field of
reproductive health.4 The fourth principle of the programme of action
of the International Conference on Population and Development (ICPD)
clearly articulates the concern that focus of population policy worldwide
3 UN ICESCR (2000) General Comment 14 : The right to the highest attainable standard of health
( article 12).
4. Zhang, Heather Xiaoquan, and Catherine Locke (2000). Implementing Reproductive Rights:
Population Debates and Institutional Responses to the New Agenda. Wellbeing, Rights and
Reproduction Research Report IV, Social Research Policy Programme. http:/www.uea.ac.uk/dev/
publink/locke/project/report4.pdf
13
must necessarily engage with issues of gender inequality whereby women

and men are differently placed in their ability to access and control
resources, be they financial or material.
Social norms of behaviour and unequal power in gender relations often
deprive women of equal access with men to food in their own homes and
prevent them from enjoying education, higher learning and involvement
at decision-making levels on equal terms with men. In many instances,
such norms deny women the recognition to make decisions relating to
their own bodies, sexuality or maternity. These inequalities are primarily
based on notions of power and control that men are deemed to have and
indeed do have and exercise in most societies.The asymmetrical relations
of power are the fundamental causes for increasing incidents of genderbased violence against women, of male and (on a broader canvass) societal
control over female sexuality, and the condoning of male irresponsibility
whether in relation to sexuality or towards their families.5
Framing reproductive healthcare from a rights perspective is a relatively
new development in Sri Lankas long established, largely successful
and internationally recognized population policy. Government policy,
supported by an extensive and well developed primary healthcare system
reaches out to most rural communities. A relatively high literacy rate
among its population, male and female, has enabled the provision
of family planning and birth control services through incentives for
voluntary steriliszation, and strengthening choice of different forms
of contraception. Following its participation at the ICPD, Sri Lanka
formulated its National Population and Reproductive Health Policy in
1998 and embarked on several policy and programme initiatives in line
with the declared objectives of the programme of action set out in the
ICPD.6 The eight goals of the policy incorporated safe motherhood
with an emphasis on reducing maternal mortality and morbidity, gender
equality, adolescent issues, elderly needs, dealing with health effects of
both internal and external migration, increasing awareness on reproductive
health, research, and AIDS and STDs awareness. A.T.P.L. Abeykoon,
5. Kottegoda, S. (2004). Reproductive Health and Gender Gaps. Paper presented at the ICPD+10:
Keeping the Promise Seminar organized by the UNFPA and the Ministry of Health, Colombo,
July.
6. Ministry of Health (2004). Implementing the ICPD POA: Sri Lanka 1994-2004, Colombo: Population
Division.
14
director of the Population Division of the Ministry of Health and

part of the team which formulated the policy, has stated that the ICPD
helped the Sri Lankan policy makers to shift from mere demographic
goals to meet the needs of the people and to emphasize reproductive
health, reproductive rights and womens empowerment.7 The National
Population and Reproductive Health Policy has also begun to play a key
role in achieving the Millennium Development Goals for Sri Lanka.
1.2 Recognition of the Impact of Conflict on Health Services

Sri Lankas ethnic conflict, was both protracted and brutal, destroyed
lives and livelihoods as well as property and the environment, and led
to cycles of displacement of thousands of families for almost two
decades. It heightened polarization and separation between the different
ethnic, linguistic and religious groups living on the island. Provision of
reproductive healthcare services was seriously affected as a result of the
conflict, and exacerbated by the tsunami of December 2004.
With the signing of the Ceasefire Agreement (CFA) between the
government of Sri Lanka and the Liberation Tigers of Tamil Ealam
(LTTE) in February 2002, Sri Lanka entered a period in which there
was an absence of full-scale war. It is widely acknowledged that dealing
with the consequences of the war and repression, as well as with issues
of reconstruction, resettlement of displaced persons and reconciliation
across the country, pose a number of challenges. The impact of conflict
and displacement on the health of affected populations and on women in
particular is now recognized as having serious implications for the wellbeing and survival of those living in conflict-affected areas.
The peace negotiations which followed the CFA resulted in six rounds
of talks between the two parties facilitated by the government of Norway
in 2002 and 2003. In addition to the plenary of the talks the government
of Sri Lanka and the LTTE set up three subcommittees which have
both an advisory and implementation capacity at the level of policy
formulation and implementation. Two among these committees, the
7. Abeykoon, A.T.P.L. (2000). Developments in the Population and Reproductive Health
Field in Sri Lanka The Post Cairo Scenario, South Asian Women: Global Perspectives
and National Trends in 1990s, Colombo: CENWOR.
15
subcommittee on immediate humanitarian and relief needs (SIHRN) and

the subcommittee on gender issues (SGI), were invested with key areas
of policy development. A needs assessment prepared by the secretariat
of SIHRN focused on eight sectors protection and resettlement; health;
education; housing; infrastructure; agriculture; livelihoods and capacity
development.8 The SGI met formally on two occasions before the
LTTE withdrew from the peace talks. In the formulation of their terms
of reference and prioritizing the work that needed to be done, women
from the government and LTTE delegations paid special attention to
reproductive health concerns of women.
In May 2003 the Consortium of Humanitarian Agencies (CHA) prepared
The Assessment of Needs in the Conflict Affected Areas.9 The
assessment highlighted areas in need of immediate and long-term action
and made relevant recommendations. In addition, the assessment takes care
to mainstream gender concerns while also recognizing and advocating for
the special needs of vulnerable groups. These vulnerable groups were
identified as Internally Displaced Persons (IDPs) and returnees, children,
single-headed households and widows, women exposed to physical and
sexual abuse and exploitation, the disabled, elderly and isolated. The
assessment recommends that appropriate access to healthcare, education
and other basic services for IDPs and returnees is an immediate need.
In the section devoted to health, the assessment observes that there is a
general lack of family planning in conflict-affected areas which has led
to higher than average fertility rates. The evaluation also notes, much
like the WHO study, that health infrastructure suffered heavy damage
or destruction,10 and that medical posts are vacant mainly in skilled and
professional categories. The delivery of reproductive care also endured
8. Asian Development Bank, United Nations, World Bank. (2003)Sri Lanka. Assessment
of Needs in the Conflict Affected Areas. Districts of Jaffna, Killinochchi, Mullaitivu,
Mannar, Vavuniya, Trincomalee, Batticaloa and Ampara.Prepared with the support
of Asian Development Bank, United Nations, World Bank..May 2003; Sri Lanka.
Assessment of Conflict-related Needs in the Districts of Puttalam, Anuradhapura,
Polonnaruwa, Moneragala. Prepared with the support of Asian Development Bank,
United Nations, World Bank..May
9. In two publications the CHA provided the needs assessments for the districts of
Jaffna, Kilinochchi, Mullatitivu, Mannar, Vavuniya, Trincomalee, Batticaloa, Ampara,
Polunaruwa, Anaradhapura, Moneragala, and Puttalam.
10.
Ibid. 45% of hospitals are either destroyed or nonfunctioning in the northeast.
16
many obstacles. Where hospitals had been damaged, obstetric care

was impeded. Family planning services and health educational services
remained insufficient. Moreover, the assessment addresses the urgent
need to establish an STD/HIV/AIDS control and prevention programme.
Inadequate facilities and shortages of drugs and suitable equipment
are endemic and have been compounded in particular by government
imposed periodic embargos on the transport of specified items to Jaffna
during the period of active conflict. The embargos on contraceptive
drugs and devices and womens sanitary needs had specific impact on
womens reproductive health and rights. The gendered consequences
included repeated pregnancies with insufficient spacing between births
putting immense strain on womens physical and psychosocial health,
domestic work and economic responsibilities.
The World Health Organization (WHO) has observed that in Sri Lanka
baseline assessments of health services in the war-affected North and East
have shown a significant disruption of preventative and curative health
services.11 The study revealed that in the districts of Ampara, Batticaloa,
Tr incomalee (in the East), Jaffna, Kilinochchi, Vavuniya, Mullaitivu (in
the North), and Mannar (in the northwest) there was grossly inadequate
provision of even essential health services. The study also revealed that
human resource shortages, in addition to the absence of basic health
infrastructures, contributed to the dismal health situation. Reproductive
services were documented as almost non-existent and maternal morbidity
and mortality were expected to be higher than in other parts of the
country.12
1.3 National Health Policy and Programmes

The Sri Lankan governments Ministry of Health is responsible for
setting policy guidelines, medical and paramedical attention, education,
management of medical institutions, providing special care and medical
and paramedical education, and bulk purchase of medicines. At the
provincial level, the Medical Officer of Health (MOH) serves as the
11. Ibid.
12. World Health Organization (2002). Health System and Health Needs of the North and
East of Sri Lanka.
17
Divisional Director and oversees health issues and institutions at the

provincial level. Provincial ministries govern provincial institutions. Rural
hospitals function in each district. At the grassroots level, midwives are
designated to serve village populations of approximately 3,000 people.
The Ministry of Health works very closely with UNICEF, UNFPA and
WHO, and has established relationships with large nongovernmental
organizations such as the Family Planning Association (FPA) and
Population Services Lanka (PSL).13
The UNFPA funds a number of programmes for the Ministry of Health.
The programmes focus on four main areas: reproductive health services;
advocacy support; education; and NGO support. The UNFPA provides
support for the Reproductive Health Services Project in conjunction with
the Ministry of Health, maternal and child health programmes and family
planning; over the last decade, 50% of Sri Lankas contraceptive needs
have been met by the UNFPA. The UNFPA also attempts to engage
parliamentarians and government leaders in gender and reproductive
health sensitization programmes though seminars and news bulletins.
Additionally, with the Health Education Bureau it has instituted education
programmes in schools and media campaigns on reproductive and sexual
health.
The FPA is Sri Lankas pioneer family planning organization. Since 1953
it has worked to provide adequate family planning services. The FPA
depends on volunteer and grassroots workers to promote and educate
on reproductive health issues and family planning. In the past decade the
FPA focused on improving knowledge and awareness of contraceptive
use and population stabilization. Its new strategic plan includes a bolder,
more rights-based approach, in which the FPA will advocate for relaxed
abortion laws and expanded services, promote AIDS awareness and
increase the rights of those affected by HIV/AIDS, and also address
issues surrounding domestic violence.
13. Interviews and discussions were held with administrators at the Ministry of Health,
Family Health Bureau, UNFPA, WHO, Family Planning Association Sri Lanka, and
Population Services Lanka, by Ms. Vivienne Choy of the WMC.
18
PSL is Sri Lankas main provider of contraceptive services. It has been

providing family planning, sterilization and mobile reproductive health
services in plantation communities and also in conflict-affected areas,
where government services are weak or have broken down (e.g., Puttalum,
Vavuniya, Trincomalee, Batticaloa, Mannar, Ampara). PSL also updates
the Ministry of Health with figures on family planning, sterilization and
contraceptive use.
To a certain extent, Sri Lankas achievements in population and family
planning are perceived as a success. For example:
In 2002 the total fertility rate and the population growth rate dropped to
1.93 and 0.85, respectively.
There is a contraceptive prevalence rate of 70 percent.
Infant mortality rate of 10.2 for females and 12.9 for males per 1,000 live
births.
Maternal mortality rate of 27.5 per 100,000 live births.14
From a distance, and especially in comparison to its South Asian neighbours,
it appears that certain aspects of womens reproductive health are stable
and ideal in Sri Lanka recognising at the same time that there remains
disparities when the data is disaggregated district-wise, particularly in the
districted directly affected by the conflict.
These statistics notwithstanding, there are reproductive health issues to
be explored and addressed. For instance, it appears that the burden of
contraceptive use and family planning falls on women. In Sri Lanka the
Family Planning Association noted in 2003 that condom use by men is
extremely low (3.7%15), as are the numbers of vasectomies in comparison
with tubectomies (2.1% compared to 21.3%16). According to the World
Health Organization, though overall the maternal mortality rate for Sri
14 Family Planning Association, Golden Jubilee Symposium Report, 2003; Department
of Census and Statistics (2005). Selected Millenium Development Goals (MDG) Indicators,
Colombo.
15. Family Planning Association of Sri Lanka (2003). This number is of the total
population of contraceptive users.
16. Ibid.
19
Lanka is low, wide variations exist among districts. In ten districts, most
of which are located in the conflict-affected North and East, maternal
mortality rates ranged from 14.3 to 9.7, much higher than the national
average.17 A key concern, however, has been the lack of comprehensive
data on the situation of reproductive healthcare available in the conflictaffected areas. In addition, abortion, which is still illegal, is one of the
leading causes of maternal mortality. Estimates of the number of
abortions performed per day in Sri Lanka range from 750 to 1,000 -a
concrete and accurate number is difficult to find given the illegality. What
is known, however, is that most abortion-related deaths occur among
poor women and/or in areas where emergency obstetric care is difficult
to access or otherwise unavailable. In 1992 induced abortions represented
a substantial proportion of abortion cases admitted to gynecological
wards in some major hospitals in Sri Lanka.18 Islandwide data show that
this trend has not declined.19
The reproductive health facilities and services in the plantation sector
is another area that shows up the differences in womens access to
information and right to make choices. The tea plantations of Sri Lanka
which were set up under British colonial rule saw the import of hundreds
of labour from South India to work on the estates. The plantation
Tamil population remains one of the poorest in the country, where the
focus on womens use of contraceptives and contraceptive methods has
coincided with the physical and mental trauma of having little power
of deciding on spacing, or the number of children, or being pushed
into sterilization either as a last resort or by their spouses for the small
monetary compensation offered by the health sector.
17. http://w3.whosea.org/drd/hlth_issues_srilanka.htm.
18. Fernando, D.N. and Rabel (1992), RAS. Induced Abortion A Hospital-based
Study, The Ceylon Journal of Medical Science, 35:1-5.
19. Hewage, P. Opinions of Health Professionals on Liberalizing Abortion in Sri Lanka
and the Actual Experience of Abortion Seekers; and Abeysekera, S. (1997).
Abortion as a Case for Human Rights Intervention: Building on the Sri Lankan
Experience, in, Reproductive Rights as Human Rights: Studies in the Asian Context. Asian Forum
for Human Rights and Development (Forum-Asia), Bangkok.
20
Furthermore, gender-based and sexual violence remains an endemic

problem in Sri Lanka.20 A strong lobby for legislative measures against
perpetrators of domestic violence saw Parliament approve the Prevention
of Domestic Violence Act in 2005. Recent research on gender-based
violence in Sri Lanka clearly illustrates the need for both preventive
and curative measures with regard to women victims and survivors of
violence to be integrated in the delivery of health services.21
Since the ratification of the Convention on the Elimination of All Forms
of Discrimination and Violence Against Women (CEDAW) in 1981 and
the adoption of the 1994 Programme of Action of the International
Conference on Population and Development (ICPD), Sri Lanka has
developed its own institutional standards and accountability regarding the
human rights of women. The Ministry of Womens Affairs formulated
the Womens Charter in 1993, and created a National Plan of Action
on Women in 1996, which was revised in 2000 and updated in 2005. It
is regrettable that the next steps with regard to making the principles of
CEDAW a part of national law and, to creating a National Commission
of Women has been delayed. In 1998 the Ministry of Health produced
Sri Lankas Population and Reproductive Health Policy. Prior to that, the
1991 population policy focused on decreasing the fertility and population
growth rate. As the population goals were met, the ensuing Population
and Reproductive Health Policy sought to address emerging issues for the
next decade.
20. Cenwor (2003). Study on Sexual and Gender Based Violence in Selected Locations
in Sri Lanka, prepared for UNHCR, Colombo; Wijemanne, Hiranthi (2003). The
Role of NGOs in Gender Human Rights and Womens Development, speech given
at FPA Sri Lanka Golden Jubilee Symposium; Samuel, K. (1999). Womens Rights
Watch, Colombo: The Women and Media Collective.
21. UNFPA (2004). A Multisectoral Response Towards Eliminating Gender Based
Violence in Sri Lanka, study prepared by Sepali Kottegoda and Ramani Jayasundere,
Colombo.
21
1.4 Reproductive Health in Conflict and Displacement Settings

The impact of a combination of factors such as poverty, loss of livelihood,
disruption of services, breakdown of social support systems and violence
on womens reproductive health is borne out in several studies on the
topic in Sri Lanka. What is more distressing is that reproductive health
may not even be considered a priority, while sometimes inappropriate
institutional responses can exacerbate reproductive health problems.22
The impact of conflict on women is also compelling. As child bearers,
women necessarily are exposed to a range of potential problems that men
do not experience. These problems can be manifested in both physical and
social ways. Physically, women can suffer from anaemia and malnutrition
during pregnancy; the absence of health infrastructure and breakdown in
livelihoods can cause them to go through childbirth in high risk situations.
Physically and psychologically, women living in an environment of
conflict and displacement may be more vulnerable to abuse, and sexual
and physical violence. The breakdown of social networks, erosion of
self-authority and lack of emotional support can also contribute to the
isolation and marginalization of war-affected women, which can in turn
place them beyond the reach of reproductive health care services..23
As a background to the current research study, the needs assessment for
SIHRN provides useful indicators on the reversal of earlier national level
achievements of good healthcare in the conflict-affected North and East,
in respect of basic healthcare services including reproductive healthcare.
The assessment records the severe shortage of medical officers, basic
specialists and paramedical workers required to conduct basic health
services. Out of 9,542 posts in the health cadre in the North and East,
34% are vacant, mostly in the skilled categories.
There is also a lack of emergency obstetric facilities at peripheral
hospitals, lack or shortage of essential drugs due to logistical factors, and
near collapse of health information and surveillance systems. It further
notes that the provision of preventative healthcare has been considerably
depleted by the conflict, and the availability of basic information needed
22. Ibid.
23. Ibid.
22
to promote healthy living and behaviour patterns is very poor. In addition,

it warns that the movements of populations and the dynamics of war
pose a risk of spreading sexually transmitted infections, including HIV.
The SHIRN Assessment also served to highlight the very gender-specific
consequences of the depletion of health and reproductive health services
to the northeast and its effects on womens lives.
Table 1
Selected Health Status Indicators for the Conflict-Affected North and East,
and Sri Lanka
Indicator
Underweight 0-5 years

Average
Male
Female
Low Birth Weight
Home Deliveries
Maternal Malnutrition
Use of Contraception
(ever used)
Current Use of
Contraception
Total Fertility Rate
Sri Lanka
North and East
24.9%
29.0%
29.8%
16.7%
4.0%
84.7%
46.2%
50.2%
42.3%
25.7%
19.4% (31.4% in
Batticaloa, 38.4% in
Mannar)
48.0%
51.3%
70.0%
36.2%
1.9
2.6
Source: SIHRN 2003. Needs Assessment Survey.
The indicators described in Table 1 suggest the serious impact of conflict

on the use of contraception, which is nearly half the national average,
resulting in increasing fertility rates of women in the North and East.
They also highlight the alarming increase in maternal malnutrition and
flag low-birth weight and malnutrition among children. The increase in
home deliveries is stark, in some instances nearly ten times the national
average.
The SIHRN Assessment is supplemented by information in the MDGs
Indicators report, prepared by the Department of Census and Statistics
23
(2005), that maternal mortality rates in conflict-affected districts such as

Kilinochchi and Batticaloa are higher than the national average (28.7 and
32.9 respectively, the national average being 27.5). This data is not even
available for other conflict-affected districts such as Mannar, Vavuniya
and Mullaitivu. In relation to infant mortality the districts of Batticaloa
and Vavuniya show higher rates than the national average.24 While the
national average for infant mortality is 12.9 for male and 10.2 for female,
the figures for the Batticaloa District are 17.4 for male and 14.4 for female,
and in the Vavuniya District it is 12.4 for male and 12 for female.25
Despite such indicators, however, policy interventions to remedy both
the causes and consequences of the impact of conflict on womens
reproductive health and rights remained marginal. The SIHRN needs
assessment for instance, while noting that the delivery of reproductive
health care services in the North and East, which was one of the best
in the country, has suffered severe setbacks, fails to recommend any
immediate and direct solutions. It identifies strengthening reproductive
health care, including the prevention of abortion, family planning, safe
motherhood, emergency obstetric care, prevention and control of RTIs,
STIs and HIV/AIDS, and efforts to address gender based violence as
medium-term needs (to be addressed in two to five years).26 It is clear
that reproductive health is mainly addressed as a health concern to be
overcome through improving health services. It does not directly address
womens access or lack of access to contraception or the consequences
of increased fertility. It does not address reproductive health as a right
and an entitlement of women. There are also no linkages made in the
analysis or in the policy recommendations, between the health indicators
and larger structural and socio-cultural and political barriers that impede
womens equality and well-being.
24 Department of Census and Statistics, op. cit.

25. Ibid.
26. Ibid.
24
2. The Women and Media Collective

Research Study
2.1 Scope and Methodology

The following section draws on the research findings from several
conflict-affected districts in Sri Lanka and addresses certain key issues
related to womens reproductive health using a rights framework. The
research was carried out in the districts of Jaffna (North), Mannar and
Puttalam (Northwest), the border villages in Polonnaruwa (NorthCentral), and Batticaloa and Ampara (East). The districts were selected
on the basis that all were affected by the conflict either directly through
military encounters between the LTTE and the Sri Lanka armed forces,
or through the large-scale entry of displaced communities from other
areas as a result of the conflict. For example, among the population in the
Puttalam District, a significant number are Muslims who were displaced
from other areas in the North.
The data collection was facilitated by representatives of communitybased organizations, comprising women activists with earlier experience
in participation in research projects, and graduates who had a strong
focus on womens concerns and well-established relationships with
communities in the respective districts; namely, the Rural Development
Foundation (RDF), Puttalam, the Mannar Womens Development
Federation (MWDF), the Polonnaruwa Womens District Committee, the
Suriya Womens Development Centre, Batticaloa, the Affected Womens
Forum, Akkaraipattu, and the Centre for Womens Development, Jaffna.
As the focus of the research was on obtaining information from women
on issues related to their life cycles and reproductive health concerns, the
selection of field researchers with specific language skills relevant in the
25
districts studied was an important factor in conceptualizing the research

project. Two representatives per district were selected to conduct the field
research.
Training on research methodology to the field researchers was given
through one workshop per each phase of the research by the WMC and
resource persons experienced in gender and reproductive health issues,
including from the UNFPA, Sri Lanka. The study was carried out between
2003 and 2005.
The research study aimed at interviewing 100 women from each district
through a structured questionnaire followed by the compiling of case
studies through a semi-structured interview with 5-10 interviewees from
each district. The final sample from all districts comprised 560 women.
In the first phase of the research study, a random sampling method was
used to identify interviewees in selected village locations in the districts. A
structured questionnaire was administered to three groups of women in
the age groups 12-18 years, 19-40 years and 41-60 years, with the aim of
capturing the life cycle experiences of women. The sample selection also
focused on the ethnic representation of the selected districts (see tables
2 and 3).
The second phase of the research study comprised compiling in depth
case studies of 30 interviewees selected on the basis of ethnicity and age.
Interviewees for the case studies were drawn from those who had been
contacted in the first phase of the research.
The total number of interviewees from the districts was as follows:
Mannar: 89, Jaffna: 104, Batticaloa: 76, Ampara: 112, Polonnaruwa: 95,
Puttalam: 84.
Tabulation of data from the questionnaires was undertaken by Digital
Base, Colombo, and the analysis of data was carried out by the National
Institute of Business Management, Colombo.
During 2005 regional consultations were held with representatives of
womens groups, organizations working on women and health issues,
medical personnel, family health workers, graama sevakas and police
officers in the different districts included in the study. Workshops were
26
held in Anuradhapura with representatives from the Puttalam and Mannar

districts and in Jaffna, Polonnaruwa and Batticaloa. The research report
draws on the information obtained through questionnaires administered
in the six selected districts, the focus group discussions held at the
regional consultations, as well as the case studies of selected women from
the districts of Puttalam, Mannar, Jaffna, Polonnaruwa and Batticaloa.
Limitations
It was envisaged that the first phase of the research would be carried
out between March and July 2004, in the districts of Mannar, Jaffna,
Polonnaruwa, Batticaloa, Ampara and Moneragala. However, this phase
had to be extended given the difficulties for researchers in some of the
districts to access a representative sample of interviewees. In addition,
difficulties in obtaining comprehensive data from the Moneragala District
compelled WMC to move its research focus from Moneragala to the
Puttalam District. The data collection and compilation of case studies in
the Puttalam District was carried out by four representatives of the Rural
Development Foundation (RDF) between February and April 2005.
While the Affected Womens Forum conducted the first phase of data
collection in the Ampara District in 2004, it was not in a position to
participate in the second phase of the research, nor was it possible to hold
a regional consultation in the Ampara District following the devastation
in the area as a result of the tsunami in December 2004. In this light,
the information from Ampara is confined to the primary questionnaire
administered in 2003-2004.
2.1.1 Ethnic Distribution of Respondents

The research focus was to capture the ethnic distribution of the distinct
populations in the districts. As can be seen in the table below, there was a
concentration of particular ethnic groups in some districts (e.g., Puttalam,
Jaffna) while in others the ethnic distribution was mixed.
27
Jaffna
Batticaloa
Ampara
13.0%
1.0%
89.0%
89
9.6%
90.3%
104
57.7%
39.7%
76
44.6%
4.5%
50.9%
112
Total
Mannar
Muslim
Sinhala
Tamil
Total
Puttalam
Ethnicity
Polonnaruwa
Table 2
District-wise Ethnic Distribution of Interviewees
25.2% 100.0%
60.0% 12.6% 95
84
560
2.1.2 Age Distribution of Interviewees

The research sample aimed at capturing the main age cohorts in which
womens reproductive health issues become more visible, as well as the
focus of most institutional and social interventions.
Table 3
Age Distribution of Respondents
Age Distribution of Respondents (%)
32.1%
44.0%
24.7%
66.2%
30.9%
8.9%
Puttlam
Mannar
32.6%
28.8%
28.8%
47.3%
51.9%
51.9%
18.9%
18.2%
19.2%
Polonnaruwa
Batticaloa
Jaffna
12-18 years
19-40 years
31.3%
39.4%
49.1%
44.6%
9.6%
15.8%
Ampara
Total
41-60 years
In all the districts, 44% of the sample was from the age category 19-40
years, since this is the period when most changes would take place in a
womans life, both socially and physically. 15.7% of the total sample was
from the age category 12-18 years, and 39.5% from the age category 4160 years.
28
2.1.3 Level of Education of Interviewees

While 72% of interviewees had formal education up to or below Grade
10 in the districts surveyed, Ampara (50%) and Polonnaruwa (36.8%) had
the highest numbers of women who had studied only up to Grade 5.
2
9
15
5
22
2
30
27
6
1
16
7
7
6
5
- 104 76
Puttalam
1
13
11
36
23
5
89
Polonnaruwa
Jaffna
None
Grade 1-5
Grade 6-8
Grade 9-10
Passed Olevel
Grade 11-12
Passed Alevel
Higher
NA
Total
Ampara
Education
Mannar
Batticaloa
Table 4
Level of Education by District
Total
16
40
22
17
9
3
2
2
1
112
8
27
24
31
1
4
95
2
19
14
31
18
84
38
129
105
172
17
49
13
13
24
560
6.7
23.0
18.7
30.7
3.0
8.7
2.3
2.3
4.2
100.0
In terms of access to education, 30% of women in the different districts

had completed grade 9-10 level of education, while 22.8% had completed
schooling in grades 1-5. This relatively high proportion of women who
had only completed up to grade 5 could be a significant factor in the
high levels of early and underage marriages and early pregnancies in
the conflict-affected areas. For example, in the Polonnaruwa District,
53.6% of women had schooling in grades 1-8; correspondingly, 54.3%
of the sample had got married between the ages 15-18 years, indicating a
possible link between school dropouts and early marriage in the border
villages studied.
29
2.1.4 Marital Status of Women

The cumulative sample from all six districts illustrated that most
interviewees were married (70.7%). Unmarried women comprised
21.25% of the sample while 7.2% were either widowed or divorced.
Ampara
Polonnaruwa
Puttalam
24
61
4
0
0
89
Batticaloa
Unmarried
Married
Widowed
Divorced
NA
Total
Jaffna
Marital
Status
Mannar
Table 5
Marital Status of Interviewees
28
67
4
4
1
104
24
46
5
1
0
76
6
103
0
0
3
112
14
73
1
7
0
84
23
46
5
10
0
84
Total
119
396
19
22
4
560
%
21.25
70.7
3.3
3.9
0.7
100.0
It is interesting to note that while the number of divorcees overall was

low, a relatively high number was recorded in Jaffna and Puttalam. The
low number of unmarried women recorded in Ampara district could be a
result of the sample selection of field researchers.
2.2 Lifecycle Approach to Reproductive Health and Rights

The research looked at how women experienced lifecycle changes and
to what extent they were aware of the stages in which these changes
occurred. It also looked at the larger structural constraints at the different
stages of womens reproductive lifecycles.
30
2.2.1 Age at Puberty

Overall, the research findings indicate that almost all women (91%) had
attained puberty by the time they were 15 years old.
Age
at Puberty
Mannar
Jaffna
Batticaloa
Ampara
Polonnaruwa
Puttalam
Table 6
Age at Puberty (Percentage)
9-12
13-15
16-19
NA
Total
16.8
73.0
8.9
1.3
89
8.6
72.1
14.4
6.5
104
40.5
58.1
1.3
3.8
76
24.1
64.2
9.4
6.2
112
26.3
64.2
9.4
95
27.3
64.2
7.1
1.1
84
Age at puberty among girls living in conflict-affected districts reflected

national averages. Interestingly, however, a comparatively lower number
of girls in the sample from the Jaffna district appeared to reach puberty
between the ages of 9 and 12 (8.6%), while in the Batticaloa sample a high
40.5% reached puberty in the same age group.
2.2.2 Age at Marriage

As the table below indicates, 31% of the sample were married between
the ages 15-18 years. 54.2% of all women in the research study had been
married by the time they were 22 years old. Compared with the data in
Table 6, there appears to be a close correlation between of puberty and
early, and therefore underage, marriage in the age group 15-18 in the
districts of Polonnaruwa, 54.3%, Ampara 50.8% and Puttalam 35.7%.
31
Mannar
Jaffna
Batticaloa
Ampara
Polonnaruwa
Puttalam
Table 7
Age at Marriage by District (Percentage)
15-18
19-22
23-25
26-29
30-33
Above 33
Unmarried
NA
14.6
19.1
21.3
11.2
3.3
3.3
26.9
0
16.3
29.8
10.5
9.6
1.9
3.8
27.8
0
21.0
18.4
17.1
3.9
6.5
1.3
31.5
0
50.8
25.8
7.1
4.4
1.7
0.8
5.3
0.8
54.3
34.5
7.4
2.4
1.2
0
14.7
0
35.7
9.5
19.0
3.5
2.3
0
27.3
2.3
Total
100.0 100.0 100.0 100.0 100.0 100.0 100.0

(89) (104) (76)
(112) (95) (84) (560)
Age
Marriage
Total
31.6% 177
22.6% 127
13.0% 73
5.8%
33
2.6%
15
1.6%
9
21.4% 120
1.0%
6
The respondents from Ampara and Puttlam were exclusively Muslim, and
early marriage may be due to the fact that the community does not have
a legally regulated minimum age of marriage.
However, it cannot be discounted that conflict-induced displacement to
Puttalam, and the intensification of inter ethnic tension and war in Ampara
over the years could also be contributing factors in young people seeking
or being compelled into early marriage. Batticaloa and the border villages
of Polonnaruwa also experienced constant dislocation and direct attacks
in the years of war. Young people in these areas were also increasingly
marginalized, often arrested, recruited into the military, the home guard27
or the LTTE. There is a perception that early and underage marriage was
a phenomenon of areas directly affected by conflict. This research study
appears to corroborate this view. As much as early marriage resulted in
underage pregnancies increasing the risk of mortality for young mothers,
it was also noted that there is a practice of young wives being abandoned
27 During the ethnic conflict, the government created a cadre of civilian males as Home
Guards who were to supplement village security activities along with the police and
the army.
32
at the time of pregnancy or after the birth of a few children and young
husbands seeking remarriage. Within the focus group discussions women
spoke of individual cases illustrative of this for example, one woman
spoke of a 15-year-old girl who had been abandoned by her husband
whilst pregnant. She delivered twins but one baby died in infancy.
For security reasons such as child abductions, parents marry
girls off at a young age. Also, parents feel that as a young
mother, she would be able to look after a young daughter
when the child becomes a teenager. (Batticaloa)
It is among the poor households that early marriage is most
evident. Children cannot be protected from sexual abuse by
males in the family. (Batticaloa, Polonnaruwa)
Focus group discussions in Puttalam, Mannar, Jaffna, Polonnaruwa
and Batticaloa brought out the relatively widespread phenomena of
early marriage of young girls. In most of these districts, the primary
reasons given for this practice, which is reportedly supported by parents,
were poverty, ignorance, and the lack of economic and social security.
There were also specific factors cited in relation to some districts. For
example, the border villages of the Polonnaruwa District had seen much
interaction with armed personnel as village men were drawn into working
as home guards or leave their homes for long periods as soldiers in the Sri
Lankan army. Most villagers depend on agriculture for their livelihoods
and many live in poverty.
Underage marriages take place in some of the backward
villages in rural areas. There are some girls of 16 and 17
years who have children of 2 or 3 years of age. Since the
mothers are children, they are unable to take care of their
child well and this causes a lot of problems in their homes.
(Jaffna)
Early marriage is seen as a solution to a life of hardship and poverty
as parents attempt to allow the young girl to move out of poverty. It
was also acknowledged that child sexual abuse within the family unit
was common, and that parents but especially mothers feel that by giving
33
young daughters away in early marriage they can protect them from being
sexually abused by males in the family. In Batticaloa, child recruitment/
abductions by militant groups was cited as the other key reason for parents
to actively support early marriage of their children, whether girls or boys.
2.2.3 Age at First Live Birth

The research study found that a significant number of women had
married at a young age and had their first child soon after. The highest
number of first child births (34.0%) was reported to have taken place
when the women were between 15 and 18 years of age.
Age at
First Live Birth
Mannar
Jaffna
Batticaloa
Ampara
WPolonnaruwa
Puttalam
Table 8
Age at First Live Birth by District (Percentage)
15-18
19-22
23-25
26-29
30-33
Above 33
5.6
19.1
20.2
14.6
7.8
-
16.3
21.4
40.4
19.0
9.5
4.7
4.7
21.4
40.4
19.0
9.5
4.7
33.0
25.8
8.9
4.4
5.5
2.6
46.2
38.8
7.4
4.4
2.9
-
34.0
29.5
13.6
20.4
2.2
-
As the above table indicates, there seems to be a further correlation

between the age of marriage and the age at first live birth in the respective
districts; 33.0% of women in the Ampara sample, 46.2% of women in the
Polonnaruwa District and 46.2% of women in the Puttalam District had
had their first child between 15 and 18 years of age. In Polonnaruwa a
high (85%) of the sample had their first child by the age of 22. In Ampara
58.8% and in Puttlam 63.5% had their first child by the age of 22. Lack
of knowledge on contraception use, sociocultural barriers that prohibit
the transmission of such information to teenaged boys and girls, lack
34
of access to contraception, and sociocultural factors preventing women

from exercising their right to control their bodies and fertility could be
contributing factors to this high incidence of early pregnancies among
teen aged girls and young women from these districts.
2.2.4 Knowledge of Contraception

Thinking that I am giving birth every year I took two packets
of pills Then when we were in the Vanni as displaced
persons we could not get the pills. After the fifth child I did
the birth control operation. (PM - Case Study, Jaffna)
I am married and have five children. My husband was a
toddy tapper and the sole income earner in the family
before he met with an accident. He does not work now. I
brought up my children by sewing but I was able to educate
them. I once had an abortion two months after conception.
I underwent an LRT operation after the fifth child because
my husband was unable to work and I found it difficult
to bring up the children. I suffered side effects after the
operation. I felt weak and I had breathing problems and got
tired easily. I am now taking medicine for it. (BG 46 years
Case Study, Jaffna)
The research study indicates that 56.6% of women in the six districts
surveyed had knowledge about contraception. Most stated that they
had obtained this knowledge from medical doctors and public health
midwives. Where the organization Population Services Lanka was
operating, some women reported that they had received information
regarding contraception from its field workers.
35
Table 9
Interviewees
who have a Knowledge of Contraception
Knowledge
of Contraception
(%)
72.6%
57.1%
63.4%
62.9%
56.2%
56.6%
Ampara
Total
19.7%
Puttlam
Mannar
Polonnaruwa Batticaloa
Jaffna
The Batticaloa district findings present the exception on this issue

with only 19.7% of respondents declaring that they had knowledge
about contraception. This could be due to a number of reasons such
as a breakdown of reproductive health services due to the conflict, or
sociocultural factors which mitigate against women accessing such
knowledge. These factors remain to be investigated.
2.2.5 Experience of Miscarriage

I am a teacher of 43 years. I first conceived soon after
marriage but miscarried three months later. I lost my second
pregnancy too and was blamed for not seeking medical
advice. I consulted a private practitioner who performed a
D and C and assured me that there was no problem. He
gave me some tablets. I conceived a third time and was
very careful with the pregnancy and even sought the advice
of the village midwife, and was very careful with my third
pregnancy but miscarried after four months. (PR 43 years Case Study, Batticaloa)
The research study revealed that women had experienced miscarriages.28
From the total sample, 16.4% of women surveyed had reported at least
one miscarriage.
28. Information was solicited as to whether they lost the baby while pregnant.
36
Table 10
Respondents who have Experience of Miscarriage of
Experience of Miscarriage of Pregnancy
Pregnancy (%)
23.0%
16.6%
16.4%
14.7%
7.8%
25.0%
6.5%
In four of the districts the number of women who had had miscarriages
was quite high - Jaffna 23%, Ampara 25%, Puttalam 16.6% and
Polonnaruwa 14.7%, as compared to 7.8% in Mannar and 6.4% in
Batticaloa. An average of 16.4% miscarriages is quite high and may be
related to poor reproductive health service delivery, stress and malnutrition
during the years of conflict, and conflict-related breakdown of health
services, restricted mobility, inability to deal with medical emergencies,
home deliveries. Repeated pregnancies, maternal malnutrition, shifts in
gendered responsibilities, which increase the work burden of women
responsible for both domestic chores and livelihood-related work, are
additional factors. These possible causal factors remain to be investigated.
2.2.6 Age at First Miscarriage

Miscarriage appears to be most common among women in the age groups
between 20 and 23 years and above 23, In the Ampara and Jaffna districts.
In the Ampara District, miscarriages appear to have been suffered by
women from all age categories.
37
Puttalam
Mannar
Batticalo
Polonnaru
Ampara
Jaffna
Table 11
Age at First Miscarriage*
12-15
0.1
16-19
19
3.3
20-23
21
3.7
Over 23
11
17
47
8.3
NA
71
82
72
81
86
80
472
4.2
Total
84
89
76
95
112
104
560
0.0
Age at First
Miscarriage
Total
* Information on age at first miscarriage of four women was not available.
Most women reported that they sought help from medical practitioners
or from midwives when they had suffered a miscarriage. Few said they
sought traditional medicine or that they did not seek any medical assistance.
2.2.7 Age at Menopause

I am aware of Menopause. I know that cessation of
menstruation happens at the age of 50. I came to know about
it by talking to other women. Sometimes I feel it is good if
it stops immediately, but I think the interest in having sex will
also stop after menopause and for family life we need sex. I do
not know how family life will be after that. I wish we can have
a workshop on this issue. (MC 45 years Case Study, Mannar)
While the question related to menopause was to be asked from all
interviewees, it is interesting to note that in all the districts only women
from the age group 41-60 are recorded to have responded.
38
Puttalam
Mannar
Batticaloa
Polonnaruwa
Ampara
Jaffna
Table 12
Age at Menopause
Age 25-30
0.6
31-35
1.3
36-40
13
8.4
41-45
21
13.7
46-50
22
14.3
51-55
15
22
14.3
NA
13
15
15
17
12
72
47.0
Total
14
22
21
31
35
30
153
100.0
Age at
Menopause
Total
From among those who responded, the following had prior knowledge
about menopause.
Puttalam
: 13 out of 14 in the age group
Polonnaruwa : 2 out of 31 in the age group
Mannar
Ampara
Batticaloa
Jaffna
Apart from the information from Puttalam, these findings indicate that
there is little discussion among women in general, and among women
from age groups other than those who are most likely to experience
menopause, about the life cycle changes in womens bodies. Framed
within the discourse of reproductive rights and the recognition of the
importance of enabling women to understand and care for their health,
such a pattern clearly points to the urgent need for comprehensive health
education programmes. The difference in the figures for Puttalam
merit further study to determine if older Muslim women traditionally
shared this information among each other or if newly emergent womens
39
groups and community-based organizations working among IDPs have

introduced discussions on womens life cycle changes.
2.2.8 Location of Child birth

My eldest sisters first child was born at home. She was
assisted by a traditional midwife. The midwife got her some
medicine from the Ayuravedic physician in Kiran. She was given
Swathavasithool (a plant extract) and a medicinal oil. Women
are also given arrack to reduce the pain of childbirth. (Ms. R, 48
years - Case Study, Batticaloa)
During the conflict we were displaced from Ottamawadi
and came to the camp for the displaced at Aliameen School
in Senapura. I attained age when I was 12 years at the camp.
I was married while in the camp at 16 to a man from Senapura
and stayed there. He is a homeguard. Following my mothers
return from the Middle East where she had gone to work as a
housemaid, my family went back to Ottamawadi when there were
fewer LTTE problems. I have four children aged 11, 9, 6, and 4.
All of them were born at home. I didnt use any contraceptive
method before but now I get (depoprovera) injections because
the children are small. My husband farmed a paddy field and
worked as a labourer. (RB - Case Study, Polonnaruwa)
As the table below indicates, it is clear that government healthcare
institutions are the primary location of childbirth among all the
interviewees in the selected districts. Health care delivered through the
government is free of charge, The majority of women reported to have
sought treatment in private hospitals where the patient is required to
pay for all services. When compared with the indicators on home births
noted by the SIHRN report in 2003, there seems to have been some
improvement in districts such as Batticaloa and Mannar.29
29. Needs assessment survey 2003,op. cit.

40
Table 13
Location of Childbirth by Number of Children Born to Interviewees
Location of Childbirth by Number of Children Born to
(Percentage)
Interviewees (%)
11.6%
7.2%
7.8%
7.1%
92.1%
92.8%
35.5%
88.3%
92.7%
63.8%
Hospital
21.2%
15.8%
78.7%
84.0%
Home
Number of Respondents:
Mannar : 61
Ampara : 82
Total Number of Respondents: 355
Jaffna
: 57
Polonnaruwa : 68
Batticaloa : 41
Puttalam : 46
However, factors such as damage to facilities available in the vicinity of
their residence, distance to hospitals, conflict-induced danger and risks,
lack of transportation, poverty, and cultural practices may have accounted
for the 15.8% of home births reported by the interviewees. Focus group
discussions revealed that some women found the requirements, such as
money for travel, and clean clothes for the duration of the stay in hospital,
to be too much for poor households, and hence women preferred not to
enter hospital for the birth of the child. In some districts, it was reported
that Muslim women were sometimes reluctant to enter hospital due to
cultural factors.
41
2.2.9 Traditional Midwives

The traditional medicine woman is known as Marauthuvivhvhi.
When a home birth is to take place she attends to it. She cuts
the umbilical cord, cleans the child, and if there are abortions
she treats them. She was an elderly lady and she passed away
recently. (Ms. ALBM, 37 Case Study, Puttalam)
Traditional midwives still play a role in helping childbirth
at home. These rural physicians help mothers recover from
the after effects of childbirth. They give powders, herbs and
oils. Elderly women engage in these medications. They give
Perunkayam to drink and also prescribe water in which Fennel
seed is boiled. (Ms. R, 48 Case Study, Batticaloa)
While the government health service structure includes the training and
placement of public health midwives around the country, the impact
of the war, internal displacement and the break up of health delivery
structures, appear to have resulted in women actively seeking the
assistance of traditional midwives for reproductive health needs. While
most traditional midwives learn their skills from older women engaged
in the same occupation, their services are mostly sought when there
are difficulties in accessing government healthcare personnel, or where
a woman has gone into labour and there was no means for her to be
transported to the nearest clinic or hospital.
A traditional midwife in Jaffna claimed that she had delivered over 100
babies in the last 20 years. She first performed a delivery when she was
visiting a pregnant mother who unexpectedly went into labour, and there
was no transport to send her to the nearest hospital. The midwife is held
in high regard in the community, particularly as she was on call during
the occupation of Jaffna by the Indian Peace Keeping Force (IPKF) when
mobility was severely controlled for the public.30
30. The IPKF was stationed in the North of Sri Lanka between 1987 and 1990.
42
2.3 Reproductive Health and Gender-based Violence

The increasing incidence of violence against women in both the public
and private spheres is primarily the outcome of gender-based social
norms and practices which condone male control over women. These
patriarchal social structures are also reflected in administrative practices
that are reluctant to acknowledge womens economic contributions to
the welfare of their families and households, as exemplified in the critical
support women income earners make (either through their earnings
as migrant workers or in the formal/informal sector). Gender-based
discrimination is continued in both policy and societal practices which
are unwilling to accept that households often comprise joint household
heads or even female heads of household.31 Where women are clearly the
primary contributors to their households, violence perpetrated against
them tends to be construed as being the result of womens own attempts
to usurp mens primary position within the family and the community.
2.3.1 Domestic Violence

It was not surprising but nevertheless disturbing that domestic violence
was quite high among the women who were part of the research study.32
As the table below indicates, in the Ampara district, 49% of women
reported having being subjected to violence. 67.8% of women in
Puttalam, 30.5% in Polonnaruwa, 28.9% in Batticaloa, 20.1% in Jaffna
and 14.7% in Mannar district also reported that they have been subjected
to violence in the home. The most common perpetrator was the husband,
though some did mention fathers, brothers and mothers as being those
who inflicted violence on them. In terms of spousal violence, most of the
women reported that the first incident of violence occurred within the
first three years of marriage. Most of them also reported that domestic
violence was not a one-off incident but was repeated.
31. Vidyaratne, S. (2004). Monetary Value of Unpaid Work and Disaggregating GDP by Sex. Colombo:
Department of Census and Statistics, Kottegoda, S. (2004). Negotiating Household Politics:
Womens Strategies in Urban Sri Lanka. Colombo: Social Scientists Association, Samuel, K.
(1999). Womens Rights Watch. Colombo: The Women and Media Collective.
Colombo.
32. The Women and Media Collective (2002). Study on Outreach Capacity of Public
Health Midwives in Addressing the Issue of Domestic Violence at the Level of the
Community: Insights from Two Districts in Sri Lanka.
43
There is a four year difference between my children but that

did not happen because we decided to space the children. It
happened because my husband fought with me over dowry
and left for four years. He assaulted me three days after my
marriage because of dowry issues. He wanted a new house
and a television set. He fights with me even about having sex.
He would force me to have sex with him even when I refuse.
He fights with me if I visit relatives in his absence. He fights
with me when he comes home drunk. Usually neighbours
intervene to settle our disputes. I had an abortion when I
was 1 months pregnant because my husband was fighting
with me. (Ms. R, 28 Case Study, Batticaloa)
Table 14
Domestic ViolenceInterviewees
(Percentage) who have Experience of
Domestic Violence (%)
67.8%
49.1%
30.5%
14.7%
35.3%
28.9%
20.1%
When women are assaulted by their husbands and admitted

to hospital, there they deny the fact that they were beaten up.
They say that they had a fall in the bathroom or they broke
their tooth by falling. They fear if their husbands were taken
into custody, they would have no one to take care of them.
The society would not accept this and it would consider the
wife as a betrayer, as she sent the husband to prison. She
44
will be marginalized. Apart from that, our culture too does

not permit us to do such things. Women dont do it because
of the fear that society might look down on them. (Focus
group participant, Jaffna)
In the focus group discussions the issue of domestic violence was
discussed in more detail. Women mentioned dowry as being a common
cause for domestic violence. One woman whose sister had been burnt to
death by her husband said:
He made her leave school and interrupted her studies to
marry her. So what right did he have to torture her after two
children were born? (Rani, Jaffna)
There was a case where a pregnant woman was assaulted
by her husband and she had a stillbirth. (Focus group
participant, Jaffna)
There are, of course, intimate links between domestic violence, sexual
relations and contraception use. In the focus groups there was frank
discussion about the experiences of women in their communities. As one
woman stated:
Sometimes the husband stops his wife from using
contraception, thinking that if she uses contraceptives
women will have extramarital relationships. Then women
have to use contraceptives secretly. However, if the husband
finds out she is doing this he punishes her with violence
accusing her of infidelity. This is a widespread situation
among displaced communities. (Focus group participant,
Mannar)
There was also a case reported in the focus group discussions in Mannar
District of a woman who died in childbirth when she was delivering her
fifth child. Her husband has refused to allow her to use any contraception.
She was a very young mother.
45
2.3.2 Forced Sexual Intercourse in Marriage

Women also spoke of forced sexual intercourse with their husbands,
especially in displaced settings. Due to the lack of privacy where the
whole family had to share one room, women try to refuse having sexual
intercourse with their husbands. However, as one woman said:
Sometimes men have forced sex with women in front of
their own children. This has made sexual intercourse very
unpleasant for women. (Workshop participant from Mannar)
I got married in 1992. My marriage was arranged by my
parents He started beating me on the very day of the
marriage. He burns me with various things. He would tie my
hands and my legs and have sex with me. He would forcibly
have sex with me even during my periods. He wants me to
agree whenever he wants to have sex. (PV, 31 years Case
Study, Jaffna)
The legal system in Sri Lanka does not recognise marital rape as a
crime.33 Prevailing socio-cultural norms strongly adopt patriarchal values
particularly in the area of sexuality and the family where women are
expected to provide, without question, sexual services to their spouses.
Womens freedom to choose when and where they will engage in sexual
activity and womens rights over their reproductive health and their bodies
are most vulnerable when it comes to rape within marriage. Women spoke
of situations where they were being forced to consume alcohol or drugs
by their husbands before having sex.
In a focus group discussion, a family health worker from Polonnaruwa
recalled that she had, on request, given a young mother her own personal
money so that the mother could take her newborn baby and spend a few
months with her mother immediately following her confinement thereby
preventing unwanted sexual intercourse and another pregnancy, to enable
her to recover and rest from childbirth and breast feed her infant for a
sufficient period of time.
33. In 1995 the Ministry of Justice brought about significant revisions in the Penal Code,
for example, recognising sexual Harassment as a crime but did not address the need
to recognise rape within marriage as a crime.
46
There are also structural factors that exclude women from marginalized
communities accessing legal redress in instances of domestic violence.
One of the prominent obstacles faced by women victims of violence
in the conflict-affected areas is that the officers in the law enforcement
system, such as the Police, are male and from the majority ethnic group
Sinhala - and dont speak Tamil, which is the language of the communities
in the area. As one woman articulated:
In Mannar, there are 3 Police stations where there are special
desks reserved to deal with problems concerning women and
children. But the complaints are taken down only in Sinhala
while all the majority of the population is Tamil. Moreover, the
Police officers who note the complaints are males with whom
women cannot share their sufferings openly. (Mannar)1
Another structural factor that places an obstacles to womens freedom
and entitlements in relation to her wellbeing, are the customary laws
which apply to Muslim women. Cases of divorce are handled through the
Qazi courts which are outside the state legal system. Women spoke about
the experiences of women who have gone through these courts
Kaasi usawi (Qazi Court) is always very partial. Women are
never represented in the Jury which is dominated by men. There
should be women representatives in the courts so that there is
justice for women. In the case of divorce, the woman is severely
insulted, the judges are very rude towards the woman. (Puttalam)
Issues such as these are important to recognise since they impact on
womens ability to access not only services pertaining to their health and
wellbeing which are provided by the State but also religious bodies.
I felt it easier to consult female medical personnel than
males. I discussed my problems freely with the midwife but
was ashamed to allow the male doctor to examine me. (Ms.
R, 28 - Case Study, Batticaloa)
As some women observed that while they were mostly treated by male
doctors, they felt more comfortable when being seen by a female doctor.
47
2.4 Reproductive Health During Time of Active Conflict

I am a mother of three children. The eldest was born in
1984. During the pregnancy I was at Ampara. There were
LTTE problems then. They were attacking police stations and
homeguards. We all lived in fear although we were not troubled.
I was admitted to the Ampara Central hospital for my delivery.
However, by 6 pm all the doctors and nurses leave the hospital
because of the LTTE troubles. My mother and father were
with me that night; there was only one other patient. When I
got my pains my father brought a doctor. He had to pay her.
She didnt work at the hospital and she was very afraid. My
child was born about 12.45 am. My parents stayed with me.
When I was with my baby my mother spotted a snake on our
bed. She shouted and someone killed it. It was a nidi mawila
and its bite is fatal. (PRIW, 42 years Case Study, Polonnaruwa)
During the war we had problems taking pregnant mothers to
hospitals if it was a caesarean. We had to inform the army
and it was through their helicopter services that patients
were transported to Anuradhapura hospital. One relative was
allowed to accompany the patient. At the hospital language
was a problem because most of the staff were Sinhalese.
Sometimes there were Tamil or Muslim staff. (MSP, 42 - Case
Study, Mannar)
The research study attempted to gather information on womens health
concerns during the time of active conflict in the different districts as
well as before the onset of the conflict, and in the period following the
ceasefire agreement in 2002.
The geographical control of areas by the Sri Lanka Army and the LTTE
during the conflict produced particularly difficult experiences for women.
They suffered human rights violations of being displaced, being arrested,
being humiliated at check points. They had their mobility severely
constrained. This dual control of territory also had gendered repercussions
on their families and relationships. Focus group discussions revealed that
some men who had married women under general or customary laws
48
observed in state controlled territory abandoned their wives and crossed

over to LTTE controlled territory and maintained second families. In
other instances men left their families in the conflict-affected regions
(state or LTTE controlled) and moved to safer locations and married
again, knowing that their wives did not have the know-how or the
resources to locate them. In still other instances men who divorced their
wives in state controlled territory moved to LTTE controlled territory
leaving little avenues available to wives hoping to claim maintenance or
take legal action through the state system, since it had no reach within
LTTE territory.
2.4.1 Childbirth During Period of Active Conflict

The research found that childbirth during period of active conflict was
highest in the age category 19-40 years in five of the six districts surveyed:
79.4% of the respondents from Jaffna, 65.5% from Mannar, 48.9% from
Polonnaruwa, and 47.7% from Batticaloa. It was also found that while
most women in the age category had birthed children before the onset
of conflict in their respective areas, there was a significant percentage
of women who had children during the period of active conflict as well:
Ampara 47.7%, Mannar 40.0%, and Jaffna 30.4%. This may indicate the
impact of irregular or nonavailability of contraceptives and reproductive
health services in these areas during these periods, which might have
denied women avenues to decide on spacing and number of childbirths.
The highest number of childbirths, 37.8% after the signing of the CFA,
was reported from the Puttalam district for the age category 19-40 years.
49
2.5 Social Exclusion and Structural Barriers to Accessing Services

In focus group discussions women raised the issue of lack of healthcare
facilities and their difficulties in accessing those that were available due
to the distance. Clinics did not have enough contraceptive injections and
the medical staff did not provide adequate information about the use of
contraceptives. Women spoke of taking too many doses or mixing up the
doses due to unclear instructions by medical staff. Certain hospitals close
to high security zones were difficult to access, such as the general hospital
and Medical Officer for Health Offices in Thelippalai, Jaffna. Patients had
to go through thorough checks by the military before getting a pass to
proceed to the hospital. This meant that they had to come early and endure
security procedures before being treated for illness.
It was not only the conflict that impinged on womens well-being, but also
the very structures in the healthcare system. In focus group discussions
held with women from Mannar, Puttalam, Jaffna, Polonnaruwa and
Batticaloa, women commonly mentioned that they were treated badly and
were humiliated and shouted at in the hospitals. They felt that abusive
treatment was especially directed towards pregnant women. Women
continued to go to the hospital when they had no alternative, but it was
not a pleasant experience for them. These experiences were reported both
from Muslim and Tamil women in Mannar and Puttalam districts as well as
Tamil women from the Jaffna District.
Focus group discussions revealed that in all the districts surveyed, women
spoke about ill treatment of pregnant women in hospital, particularly those
located in the border areas of the district. In most government health
facilities in these areas, most of the staff in the hospitals were Sinhala
speaking, and often Tamil-speaking women did not understand what was
happening around them and what instructions they were being given about
contraceptive use. In Batticaloa, Tamil and Muslim women pointed out
that there were times when pregnant women in the rural areas sought out
traditional midwives for care rather than go to institutional health facilitites,
where they were often harassed and sometimes subjected to physical abuse
such as slapping and pinching by hospital staff in the maternity wards.
50
Number of Childbirths Before and During Time of Active Conflict and After
the CFA
Period of
Pregnancy
Age Group
12-18
No
% of
Subtotal
Age Group
19-40
No
% of
Subtotal
Age Group
41-60
No
% of
Subtotal
Total
No
%*
% of
Subtotal
JAFFNA
No. of
respondents
Before
3.9
61
66.3
65
33.5
During
81
79.4
28
30.4
109
56.1
After
17
16.6
3.2
20
10.3
Subtotal
childbirth
102
100.0
92
194
100.0
37
26
63
100.0
BATTICALOA
No. of
respondents
Before
16
23.8
39
67.2
55
43.6
During
32
47.7
11
18.9
43
34.1
After
100.0
19
28.3
Subtotal
childbirth
100.0
67
100.0
58
22
17
40
13.7
100.0
28
22.2
126
100.0
POLONNARUWA
No. of
respondents
Before
33.3
24
25.5
49
50.5
74
38.1
During
46
48.9
22
22.6
68
35.0
After
66.6
24
25.5
26
26.8
52
26.8
Subtotal
childbirth
100.0
94
100.0
97
100.0
194
100.0
32
20
55
PUTTALAM
No. of
respondents
24
16
41
Before
12
16.4
48
72.7
60
42.8
During
13
17.8
14
21.2
27
19.2
After
100.0
48
65.7
6.0
53
37.8
Subtotal
childbirth
100.0
73
100.0
140
100.0
66
100.0
51
MANNAR**
No. of
respondents
Before
During
After
Subtotal
childbirth
38
18
56
5.3
32
58.1 37
25.0
61
65.5
22
40.0
83
56.0
27
29.0
1.8
28
18.9
93
100.0
55
148
100.0
100.0
AMPARA
No. of
respondents
Before
14
10.6
45
51.1
59
25.9
During
83
62.8
42
47.7
125
55.0
After
100.0
35
26.5
Subtotal
childbirth
100.0
132
100.0
46
20
88
72
1.1 43
100.0
227
18.9
100.0
The state health care system has recognized that women give birth to
babies with low birth weight because of malnutrition and has put in place
a programme to provide supplementary food during pregnancy. However,
women who live in displaced communities or communities which were
badly affected by the conflict found it hard to access such entitlements.
Women from Jaffna mentioned that sometimes when the supplementary
foods reached their areas it was contaminated, and there was once an
incident where a pregnant woman was hospitalized after consuming such
contaminated supplementary food.
A midwife from Jaffna who was part of the research study spoke of her
experiences during the conflict years. Over the past 26 years, she had
delivered more than a hundred babies. She said that usually families go to
the hospitals, but in instances where it is too late or this was not possible
due to the war, she had to perform deliveries. She noted that when the
Indian Peace Keeping Force (IPKF) was in Sri Lanka in the late-1980s,
travelling during the night was not allowed, so there were more deliveries
at home. She recalled how on one occasion when the womans life was in
danger and they were trying to get to the hospital, the IPKF had beaten
the driver of the vehicle and only after much pleading had allowed them
through.
52
2.5.1 Reproductive Choice as Freedom

Social, political, economic and cultural environments play a key role in
enabling women to make decisions regarding their own reproductive
health, as well as facilitate their access to reproductive health services
made available in their specific localities.
Women from Jaffna and Batticaloa claimed that during the time the LTTE
was in control of Jaffna, it had discouraged the distribution and use of
contraceptives through government and private hospitals. This had
understandably a huge impact on womens reproductive health.
During the war period when the LTTE was in control, they
prevented us from using contraceptive methods. They
only permitted mothers who have five to six children to
use contraceptives and the mother had to be over 35 years.
(Focus group participant, Jaffna)
In the last two years, following the Ceasefire Agreement, it was reported that
the availability of contraceptives had improved. Women from Puttalam
reported that reproductive healthcare also improved in the post-2002
period. However, there appear to be strong controls over womens ability
to access particular types of reproductive health facilities. The procedure
to obtain sterilization for a woman was decided by the government health
services and required the completion of an eligibility form approved by
the Family Health Worker (also referred to as the Public Health Midwife),
the Graama Sevaka, and the husband.34 The form requires that the
applicant understands that after the sterilisation procedure, s/he will not
be able to have any more children, that sterilisation is a surgical procedure
and the details of the procedure, attended discomforts, possible risks and
the benefits to be expected have been explained to the applicant by health
34. Ministry of Health (1983). National Family Health Programme Declaration of
onsent for Sterilization, Health: 1198 (revised 1983). The Family Health Worker/Public
Health Midwife is a cadre of the Ministry of Health whose mandate is to work at the
village or household level to ensure that pregnant women access health care services and
to advice household members on the health and well being of children. The Graama
Sevaka is a government administrative employee who is based at the village or urban ward
system.
53
personnel, that the sterilisation operation is irreversible and that there

are temporary methods of contraception which can be used instead of
sterilisation for planning a family.35 While the woman signs such a form,
it has to be countersigned by her spouse and by an authorized officer.
After 35 years a woman can get LRT (sterilization) done36.
The husbands consent is needed. Also if the woman has
five children and the youngest is over five years, the VOG
(Visiting Obstetrician-Gynecologist) will do LRT. If her age
is 35 and her youngest child is less than 5, she may not be
able to get LRT. For example, if the child died in a tsunami,
a woman who had LRT would not be able to have any more
children. (Focus group participant, Batticaloa)
LRT is not done very often. Sometimes, if 15 women are
sent for LRT they are given different dates to come to the
hospital. Sometimes, women get pregnant before the LRT is
done. (Focus group participant, Batticaloa)
According to government regulation, if her health is not at risk, a woman
is considered eligible to request sterilization after three children. However,
it was reported that in Batticaloa, women in the rural areas are discouraged
from obtaining sterilization if she has less than five live children and is
less than 35 years of age. Focus group discussions in Jaffna brought out
the fact that there is pressure exerted indirectly on women by the LTTE,
which actively discourages women from obtaining sterilizations on the
grounds that the war had reduced the population in these areas. It was
reported that the persons authorized to approve a womans application
for sterilization are pressured not to give approval if this criteria is not
met. This had serious implications on a womans ability to obtain legally
available reproductive health services for her own well-being.
Officially the public health midwife in the area is responsible for advising
(married) women on family planning and contraceptives, while also
directing women to access contraceptives. It was revealed that many
35. Ibid.
36. Litigation and Resection of Tubes is a medical procedure performed under local
aneasthesia where the patient is expected to be able to return to her home after a few
hours.
54
women were ignorant or suspicious of most forms of contraceptives

and believed that these were harmful to their health. While most women
were aware that contraceptives were available that enabled planning of
the number of children, many reportedly believed that there were adverse
health implications of such interventions and feared that they would
suffer as a result.
Women living in the LTTE controlled areas in the Batticaloa district, for
example, were reported to have less access to reproductive healthcare
services, and pregnant women were less likely to be regularly monitored
through the government network of healthcare providers. Although
public health midwives who visit these areas advise such women to admit
themselves in time for delivery to the nearest hospital, often, due to
various reasons such as lack of transport facilities, funds to pay for travel,
fear and lack of confidence, women were reluctant to do so. There was a
much higher dependence on traditional midwives in these areas.
2.5.2 Informed Choice

A woman had six children. I felicitated her. I told her that
she was very lucky. But she said that she cannot be happy
over it. Her husband is a drunkard and forces her to have
children one after another. These children are a result
of my state as a victim of subordination. (Focus group
participant, Puttalam)
A womans right to decide on the number of children she has is a critical
part of the rights discourse on womens choices and freedoms related to
their own bodies. This is an area which needs to be addressed urgently
to enable users to make informed decisions with regard to the type of
contraceptive methods which are available. At present, there are few
institutions, for example, the Family Planning Association, which provide
such information to their clients. In most instances, women seeking
contraception have little knowledge of what particular methods are best
suited to them or why. There is, overall, inadequate discussion on the side
effects of any particular method advocated.
55
Women had few avenues to access information about reproductive health.

They discussed some of their concerns with friends. In the sample from
Mannar district, for example, 73% of the 84 women who responded
to the question said that they had not been informed about puberty at
the age of getting their first menses. One young woman explained that
even though reproductive health is part of the science syllabus, it is not
explained adequately, and since there were boys in the class the girls never
dared to ask any questions.
I dont know how pregnancy takes place. I dont know if
by being friends with boys and talking to boys, girls can get
pregnant. (Young woman interviewee, Jaffna)
Information and awareness-raising on reproductive health and rights is
not as yet an integral part of the education system despite efforts made
recently by the Ministry of Education in collaboration with the Ministry
of Health to distribute relevant publications to senior students in
government schools. Cultural norms and practices also play a fundamental
role in controlling access to information. Muslim women spoke about
how within Islam (as practiced in Muslim communities considered for
this study) sex education was banned, increasing the vulnerability of
young girls who are then married at a young age and dont know what
is happening to their bodies. In Polonnaruwa, women spoke of the high
incidence of underage relationships that result in early marriage, as well as
the prevalence of incest and sexual abuse in the communities they live in.
In focus group discussions, it was agreed by participants that teenage
boys and girls were sexually active and that there was an increasing trend
especially in the more impoverished areas of young people dropping out
of school, leading to early marriage. Iin welfare centres set up to house
communities displaced by the conflict, young people were more likely to
be exposed to sexual conduct of adults and others. An overwhelming
majority of the community workers and family health workers who
participated in focus group discussions in all the districts were very much
in favour of such programmes being introduced to boys and girls as well
as men in the communities. There was a strong call for the introduction of
sex and reproductive health education in schools to students at Ordinary
and Advanced -Levels. Some of them were aware of the education
56
material created by the Ministry of Education Yauvana Paruvam/Yauvana

Samaya (The Age of Youth) and felt that school principals and teachers
should introduce this into schools without delay. However, women spoke
of the strong resistance to this move that came sometimes from school
authorities and also from parents who pressured school authorities to
withdraw the distribution of the book.
Access to informed choice is also related to the issue of menopause. It
is important that information regarding menopause is included in social
education packages and community healthcare programmes, particularly
in light of the fact that this is a critical life change in every womans
life, and the psychosocial implications could be of a serious nature. Most
women who had experienced menopause had had no prior information
regarding this stage of their lives.
2.5.3 Abortion
We used to eat pineapple or raw papaya to abort pregnancy.
(Focus group participant, Jaffna.)
I will tell you about some of the traditional methods used to
get rid of unwanted pregnancies. Some women eat tender
papaw, tender pineapple and tender parts of the coconut
bark to induce an abortion. I had an abortion when I was
1- months pregnant because my husband was fighting
with me. I suffered from stomach pains subsequently and
got medicine for it from a doctor but I didnt tell him about
the abortion. (Ms. R, 28 - Case Study, Batticaloa)
An area which remains of critical concern is the criminalizing of abortion
irrespective of the circumstances of pregnancy. There has been no
change in the law despite the inclusion in the National Plan of Action
on Women since 1996, of specific situations of vulnerability of women
who may have become pregnant as a result of rape, incest or have been
found to have foetuses with congenital abnormalities.37 The number of
abortions islandwide has been estimated to be approximately 180,000 per
37. Ministry of Womens Affairs (1996). National Plan of Action on Women. Colombo.
57
year (15,000 per month).38 The health costs of complications arising due
to unsafe abortions are also very high. It is estimated that at least 20% of
hospital beds in gynecological wards in Sri Lanka are occupied by women
who have undergone unsafe abortions.39 A study done by Rajapaksa and
De Silva (2005)40 indicates that abortions were most predominant among
married women in the age group of 25-39, who already had two or more
children. Induced abortions were mainly sought by women for spacing
and limiting families. The authors also note 14% of the study sample had
had a previous abortion.
During the past three decades, there have been two failed attempts to
change the draconian abortion law, which now falls within the purview
of the Penal Code Sections 293 and 303.The first attempt in the late
1970s was to decriminalize abortion and the second attempt in 1995 was
to decriminalize abortion under specific situations such as rape, incest
or where the foetus is found to be congenitally abnormal.41 While the
Womens Charter (1993) recognizes the right of women to make decisions
relating to number and pacing of children, the National Plan of Action
on Women (1996/2000) calls for decriminalizing abortion under the
specific conditions (as in the draft abortion bill of 1995) and in situations
of contraceptive failure.
Despite the fact that available data indicates that most abortion seekers
are married women, and that medical complications arising from illegal
induced abortions has emerged as the third highest case of maternal
deaths in the country, the legal and policy-making bodies appear to be
unwilling to respond to this urgent need to decriminalize abortion under
these specific situations.42 It is imperative that institutional mechanisms are
put in place which would safeguard women from undergoing unwanted
or unplanned pregnancies.
38. Ministry of Health (2004). Op. cit.
39. Abeysekera. op. cit.
40. Rajapaksa, L. C. and De Silva I. (2005). A Profile of Women Seeking Abortion,
unpublished report for UNFPA, Colombo. The study was conducted among 786
women from urban and rural backgrounds who were seeking abortions from known
abortion providers.
41. Ibid.
42. Kottegoda, op. cit.
58
Although the WMC research study did not elicit information on induced
abortion as a widespread phenomenon, most likely also due to the fact
that women are aware that abortion is illegal, it was women in the age
categories 19-40 and 41-60 who reported that they had resorted to
induced abortions. Of the 16 abortions reported in the study from all
districts, 10 (62.5%) were by women in the age group 19-40. According
to the research findings, six women said they made the decision to abort
the pregnancy and five said that it was their husbands who wanted the
abortion carried out. The remaining six women said they consulted with
their husbands in making the decision. The most common reason for
seeking an abortion was financial problems in the family and the inability
to maintain another child. Women spoke of the different methods by
which they know abortions are induced.
2.6. Impact of the Tsunami Disaster on Womens Reproductive

Health and Rights
The Tsunami that hit Sri Lanka in December 2004 devastated the major
part of the coastline of the east of the country as well as the northern
and southern coastal areas,
According to Ministry of Health assessments, 72 hospitals were damaged
by the tsunami, along with 363 other facilities such as mental and
childcare clinics, and central dispensaries.43 A study carried out on the
impact of the tsunami on reproductive health services found that of
the 92 Medical Officer of Health (MOH) Divisions 42 were affected;
where the impact was heaviest, 10 out of 12 were affected in Kalmunai,
Ampara (Eastern Province), 6 out of 11 in Batticaloa (Eastern Province),
1 of 2 in Mullaitivu (Northern Province) and 2 out of 4 in Kilinochchi
(Northern Province).44 Womens experiences of being displaced after the
tsunami, living in congested environments and facing domestic violence
had not been very different from womens experiences due to the conflict.
In the initial months, women found it difficult to access health services,
especially reproductive health care services, due to being displaced and
43. www.tafren.gov.lk
44. UNFPA (2005). Assessment of Reproductive Health Services in Tsunami Affected
Districts of Sri Lanka, UNFPA in collaboration with the Regional Health Authorities
and the Family Health Bureau, Ministry of Health. Colombo.
59
having no transport facilities. The rudimentary healthcare that was put

in place after the tsunami did not effectively reach mothers with young
babies and pregnant women. Women spoke about their concerns about
being forced to have sex with their husbands in the camp setting, or
worrying about the safety of their daughters who got their first menses in
the displaced camps, and not being able to perform the rituals associated
with this culturallysignificant event. Women were also distressed about
not having proper sanitary facilities when they got their periods.
There were been reports of an increasing incidence of domestic violence
which women were being subjected to within welfare camps as well as
in temporary shelters. Among the causes for such incidents appear to be
men blaming women for the loss of children to the tsunami; the lack of
privacy for intimate sexual relations between spouses and mental trauma
resulting from the aftermath of the tsunami; men using relief monies
for personal rather than household needs; and the unemployment and
insecurity experienced by men as familiar gender roles were undermined.45
The tsunami changed family and social structures in the affected areas.
More women died than men in the tsunami. It became common for men
who lost their wives to start new relationships with other women. Young
girls and boys got involved in relationships in the camp settings. In this
context, unfortunately, there were few, if any, systematic interventions
to create awareness on reproductive issues among young people in the
tsunami-affected areas.
As one researcher points out, the social fabric in some areas in the east
underwent much change after the tsunami creating concern for children
left behind after the death of their mothers:
As a result of the tsunami, widower-headed families have sprung up, which I think will
have adverse effects for the children, particularly for young girls. As the surviving men
are young, it is likely that they will remarry as it is acceptable in our culture. After they
got an amount as death relief from the government, marriages are increasingly taking
place. Some have even got big dowries from their new brides.46
45. CATAW (2005). Briefing Note to Unifem, The Women and Media Collective.
Colombo.
46. Ismail, Zulficar (2005). Interview. Options, Vol 36, Issue 1.
60
From the North and East conflict-affected areas which suffered most
damage and loss of life during the tsunami, both the government and
LTTE made interventions to address the concerns of the survivors. An
interview with a key woman leader of the LTTE revealed that many
women survivors suffered much trauma and needed psychosocial support
to deal with their personal tragedies.
We have seen mothers who have lost the babies to the
tsunami not in control of themselves and unable to come
to terms with what has happened. I have seen mothers
carrying dead babies in their hands refusing to accept that
they are dead. They continue to kiss and caress them as if
they are alive. They had great trouble accepting that the last
rites needed to be performed on their babiesThe loss of
children has shaken us deeply and it is very difficult for us
to even think about it.47
The Affected Womens Forum from the Ampara district, which facilitated
this research there was unable to continue working with the second phase
of data collection as a result of the tsunami which devastated large areas.
47. www.tamilnet.com Interview with Ms. Thamalini. Options, Vol 36, Issue 1, January
2005.
61
2.7. The Research findings

This research study focused on the specific concerns and needs of
women living in conflict-affected areas of Sri Lanka, in relation to their
reproductive health and rights.
It has brought to light a range of general issues with regard to reproductive
health-care services in the country and the need for legal and policy
reform at the national level in a range of areas concerning delivery of
equitable and high quality reproductive health care to all Sri Lankan
women in a manner that fully respects their human rights. It has also
made visible some specific issues related to the delivery of reproductive
health-care during the conflict that speak to the physical, material, sexual,
psychological and political consequences for womens reproductive
health in such an environment.
The research highlighted the diverse ways in which the conflict and the
tsunami changed family and social structures in the conflict-affected areas
of the island. While in the tsunami, more women died than men, the
conflict has led to the death, disappearance or absence of men. In the
process of displacement and living in camps and welfare centres, as well
as due to collapse of normal social strictures, the lives of young people
have been opened up to often causal relationships. In all these cases, the
changes in social and family structure have led to new forms of social
and sexual relationships emerging, In this context, it is necessary to put
in place systematic interventions to create awareness on reproductive
and sexual health issues among adults and adolescents in the conflict and
tsunami-affected areas.
The research also focused on the need for comprehensive and systematic
social and institutional support for women living in conflict-affected areas
that would help them to deal with the vacuum created by the breakdown
of social/emotional/familial support networks because of the conflict
and displacement. This requires an understanding of the climate in
which women face many challenges. The multiple ways in which the
conflict brought about changes in womens gendered roles within the
household and in society must be acknowledged. Recognition of women
as primary income earners and as head or joint head of household is
62
extremely important, including in the design and implementation of

policy interventions.
Our findings also point to the need for the state to give priority to rebuilding
damaged or destroyed infrastructure in the conflict and tsunami-affected
districts, and recruiting staff for vacancies in medical cadre positions
throughout the conflict-affected regions, paying particular attention to
providing at least primary healthcare services to the less accessible and
marginalized areas. Providing emergency obstetric facilities at peripheral
hospitals should also be prioritised. Enhanced incentives could be
offered to those who choose to work in areas which are particularly
disadvantaged, continuing a practice that was put in place during the
years of conflict. The incidence of home births must be lessened by the
provision of adequate and accessible health services and facilities in the
vicinity of communities affected by the conflict. Women from poor and
marginalized communities in particular must be assisted with relevant
support services such as access to transportation.
The research affirms the findings of other studies and surveys relating
to women in conflict-affected parts of Sri Lanka in terms of the broader
gendered socio-cultural context as well. While it is clear that the multiethnic, multi-cultural and multi-religious nature of Sri Lanka calls for
the exercise of extreme care and sensitivity when approaching matters
relating to womens rights and reproductive rights in particular, there
can be no doubt that laws and policies that affirm womens equality and
protect them from violence and discrimination have to be put in place.
Working together with religious and community leaders is essential in this
context. In particular, the research highlighted the need for discussions to
explore avenues for more gender-responsive structures and procedures
within religious bodies, such as the Qazi Courts, to enable a strong and
non-discriminatory approach to gender based issues within the Muslim
community.
The low age of marriage has emerged as a factor having a serious impact
on the reproductive health of women and girls living in conflict-affected
areas. Understanding and analysing the root causes of this phenomenon
such as poverty, a climate of insecurity created by the conflict and
the psycho-social impact of conflict must lead to the development
63
of programmes and policies that will actively discourage under-age

marriages and provide livelihood and other forms of support to families
to enable the retention of girls within the family as much as possible.
In doing so, attention must be paid to the vulnerability of children to
sexual abuse within the family, and devise relevant programmes that will
focus on prevention of violence against children within the family. The
implementation of the law relating to the minimum age of marriage
should be linked to making information available on both the legal
implications and the negative health consequences of early marriage to
the young couple and their families. At the same time, there is a need to
reopen discussion with the Muslim community on the issue of the legal
minimum age of marriage.
The research also highlights the urgent need to deal with and prevent
spousal violence which is often repeated and starts very early in marriage,
and violence within the family. The gendered causes of spousal violence
need to be identified and remedial action taken with appropriate counseling
for women and also for men, as well as legal assistance, psychosocial
support and other services including the provision of shelters. The medical
implications of domestic violence, in particular the health consequences
of violence during pregnancy, must be addressed with adequate support
for the women affected. The Prevention of Domestic Violence Act must
be widely disseminated so that persons subjected to such violence can
access the courts for protection orders and prevention of the recurrence
of such violence. Judicial, law enforcement, medical and social services
personnel must be made aware of the provisions of the Act and given
adequate gender-sensitive training so that the Act is made effective at
the community and institutional levels. At the same time, issues were
raised regarding bigamy, and steps must be taken to prosecute men who
contract bigamous marriages, and courts must more rigorously enforce
the payment of maintenance to women and children.
The need for public education for adults and children regarding reproductive
and sexual health emerges as an essential factor if the healthcare system is
to improve access to informed choice for all Sri Lankan women and men.
Cultural norms and practices which play a fundamental role in controlling
access to information on reproductive health matters must be dealt with
64
in a culturally sensitive manner. Comprehensive reproductive and sexual

health education programmes should be provided at the level of schools,
universities and at the local level within the community, framed within the
discourse of reproductive rights and recognising the importance of choice
in decision-making. Recognition of adolescent sexuality and factors such
as an increasing trend in school dropouts and an insecure future that may
result in under-age marriage and premarital sexual relationships etc. should
be taken into consideration in devising programs of sex education and
responsible sexual practices for young people. Since there is an obvious
thirst for information and knowledge, and young people referred to the
media as a potential source of communication, appropriate programmes
aimed at youth can be disseminated through the media, including new
forms of social media.
Information and awareness raising on reproductive health and rights
should be an integral part of the education system. The Ministry of
Education together with the Ministry of Health need to address the sociocultural barriers that have emerged against the distribution and discussion
of their publications Yauvana Paruvam/Yauvana Samaya (The Age of
Youth) - to senior students in government schools. Efforts must be coordinated and strengthened to ensure that this excellent publication is used
by the relevant groups of students through the schools without delay. In
order for serious reproductive and sexual health education programmes
in the secondary schools to succeed, close collaboration with teachers and
parents as well as religious and community leaders is critical, given that it
is public resistance from these sectors that has blocked implementation
of the programmes that have been prepared so far.
The promotion of the use of contraceptives and family planning
emerged as a key concern of many of the women who participated in
the research. The establishment of Well Woman clinics in government
hospitals covering all Districts, with adequate resources and trained
personnel, should be a priority of the healthcare system. Information on
contraception its benefits as well as its side effects - must be readily
available to women in user friendly and accessible forms in all three
national languages at clinics, hospitals and other informal settings such
as womens organizations. Advice on contraception must be accessible
65
through Family Health Workers and other female medical personnel

who speak Tamil or Sinhala (as appropriate) so that women can make
informed choices on contraception. Women and men must be encouraged
to discuss their fears and doubts about contraception and its effects of
their reproductive health and sex lives. Contraceptive devices and services
must be made freely available to women and men, and wherever possible
provided free of charge. Men must also be educated and encouraged to
use contraception and practice safe sex, including the use of condoms, as
well as obtain vasectomies, so that the onus on contraception use is not
placed entirely on women.
Another key factor that emerged as a concern was the fact that protocols
and regulations for obtaining permanent birth control methods such as
sterilization or Ligation and Resection of Tubes (LRT) for women must
be relaxed so that women do not have to obtain the permission of their
spouse. In addition, the current protocols require authorization by Family
Health Workers, and by a local government official often the Grama
Sevaka. This procedure should be seriously and critically reassessed in
terms of how it impinges on the right of a woman, or of a couple, to
decide on the number of children in the family. The decision to obtain
such a procedure should be left to the woman and/or couple concerned.
A number of practical concerns regarding the delivery of reproductive
and other healthcare services in the conflict-affected areas also emerged
from the research. The need for adequate numbers of judicial, law
enforcement, medical and social services personnel who speak and work
in Tamil, at least at the district level, was seen as essential, so that Tamil and
Muslim women could access these services for assistance and redress with
confidence. There were also concerns raised regarding the need for staff
at hospitals to be trained and held accountable for the respectful treatment
of all patients, in particular of women seeking reproductive healthcare,
with special regard to pregnant mothers. Continuous performance
indicators and standard procedures must be put in place and impartially
implemented, so that complaints can be easily identified and addressed.
The performance of all medical staff at all levels must be monitored and
user responses to quality of care should be an integral part of procedures
to enhance quality of service delivery in government hospitals and clinics.
66
In a context where there continue to be staffing shortages in the

reproductive health care services in the conflict-affected areas, the role of
traditional midwives, particularly in poor and marginalized communities,
must be recognized. Their skills must be acknowledged and their work
supported and strengthened where possible. Since Family Health
Workers, the majority of whom are women, are required, especially in
the rural areas, to cover long distances to visit homes in the course of
their duties, they should be provided with more appropriate and efficient
transportation such as motor bicycles.
2.8 Conclusion
As in other conflict situations women have been affected in particular
gendered ways by violent conflict and war in Sri Lanka, particularly in the
North and East and the border areas adjacent to them. As the internally
displaced, as refugees, as survivors of war offensives, landmine injuries and
sexual violence, as mothers, and girls, as wives and widows, as combatants
and as civilians, women have experienced conflict differently from men.
While women are victimized by war, they are not merely passive victims as
is often portrayed.1 In the course of Sri Lankas war and conflict women
have begun to assume new roles of leadership within their families
and communities, becoming providers for their families, assuming sole
responsibility for the household and holding together communities in
very adverse circumstances. Many women are today confident heads of
household; many have moved into the public domain to assume roles
previously played by men, negotiating with local authorities, police,
military and the combatants to carry on with their day to day lives.2 They
are more prominently visible in the sphere of economic activity and have
gained invaluable experience and expertise in negotiating and interacting
with state authorities and government officials.
1. Womens Concerns and the Peace Process Findings and Recommendations, International Womens Mission to the North East of Sri Lanka 12th to 17th October 2002,
Colombo: Women and Media Collective.
2. Ibid.
67
However, Sri Lankan women in general have little control over processes
that determine the course of economic, social and political decisionmaking in terms of designing programmes, policies and laws. During the
years of conflict, women were rarely, if ever, involved in decision-making.
In the years following the signing of the CFA, the continued exclusion
of women from the peace process is a matter of grave concern. Through
this exclusion, there was a very real possibility that the programmes for
reconstruction, rehabilitation and resettlement that are set in motion
as a consequence of the negotiations will be insensitive to the needs
and concerns of women and will, perhaps, even play a negative role in
relegating women once more to the private and domestic spheres of
life and activity. Such a process could well negate the critical role that
women have played throughout the decades of conflict in holding their
families and communities together.
Womens right to control their bodies, their reproductive functions and
their sexuality are crucial to enable their autonomy, freedom and their
lives and life decisions. However, little detailed and gender-sensitive
information is available on the consequences and impact of conflict
on womens reproductive health and rights. This study and available
indicators suggest the serious impact of conflict on the reproductive health
and rights of women. Reproductive health policy cannot be ignored or
relegated to long-term policy interventions; it must be considered both an
immediate need as well as a right that has to be met immediately. It is our
belief that womens participation in sustainable peace building includes an
informed and active participation in policy-making at all levels of planning,
monitoring and implementation. As Sri Lanka must necessarily engage in
conflict resolution, peace building and social transformation, it becomes
even more imperative that women have a say in the new interventions
that seek to rebuild their lives, societies and communities. As the Sub
Committee on Gender Issues to the peace process noted, reproductive
rights have to be a key focus of policy interventions. Women must
bring to these initiatives their lived local-level experiences that ensure a
framework for a just and sustainable peace that involves all communities
affected by the war.
68
The research in particular revealed the need for serious attention to be

paid to issues relating to womens reproductive health and rights through
policy and law reform.
Key among these are:
Reproductive healthcare policy must effectively integrate a rightsbased framework that looks at womens reproductive health from a
lifecycle approach and that incorporates internationally recognized
norms and standards, for example those defined by the World Health
Organization (WHO) and the UNFPA.
Access to health information and monitoring of the health status
of women through their lifecycle must be an integral part of health
care in the country, but especially in those areas where health service
delivery has been disrupted due to the conflict.
Reproductive health policy must directly address the linkages between
health indicators and the structural, socio-cultural and political barriers
that deny womens equality and equitable access to entitlements,
including those relating to reproductive and sexual health and rights
as well as barriers that impede womens full and equal participation in
decision-making, especially about their reproductive health.
The issue of women being coerced into sexual relationships within
a marriage emerged as a major concern when discussing womens
right to make choices regarding reproductive matters. The need for
legal and social recognition of womens rights over their reproductive
health and their bodies calls for the recognition of marital rape as
a criminal offence, as well as for public awareness to ensure that
the environment in which the rights of husbands are socially and
culturally given priority.
The decriminalization of abortion also remains a critical issue in the
arena of reproductive rights in Sri Lanka. The National Plan of Action
on Women (1996/2000) called for the existing law to be liberalized to
allow for legal abortion, under strict regulation, in cases of cases of
rape, incest or where the foetus is found to be congenitally abnormal.
69
Making this a reality should be a key focus of reproductive health and

rights advocacy in Sri Lanka.
The Women and Media Collective, and the partners at the national and
local level who were involved in this research, remains committed to
taking forward the findings of this study and bringing about both shortterm and long-term changes in laws, policies, programmes as well as in
social and cultural attitudes towards women, in order to ensure that all Sri
Lankan women can exercise their full human rights in all areas including
in the area of reproductive health and rights.
70
3.0
District Level Research Findings
71
72
73
3.1 The Puttalam District
In 2002, at the national level, the population in Sri Lanka living below the
poverty line was estimated to be 22.7%; that of males living below the
poverty line was 23.0% and of women was 21.5%.48
The Puttalam District is one of the poorest in the country. In Puttalam,
the corresponding figures for the population living below the poverty
line in 2002 were 31.4% of males and 30.8 % of women.49 In terms
of household income and consumption per head (share of poorest
quintile 1/5th in national consumption), it was found that in Puttalam,
13.5% of female headed households were among the poorest while the
corresponding figure for males was 11.5%.50
In October 1990 all the Muslims living in the northern districts were
expelled by the LTTE; the vast majority of them were de facto resettled
48. Department of Census and Statistics (2005). Selected Millenium Development
Goals (MDG) Indicators, Colombo.
49. Ibid. The computation is done on the basis of the sex of the head of the household.
50 Ibid.
74
in the Puttlalam District. The IDPs coexist with host populations of

Muslims resulting in a heightened sense of tension periodically on already
overstretched resources in the area. Some of the Muslims from the
north continue to live in welfare camps while others have been located
in resettlement villages and, those with means have been able to buy
private property.
The Puttalam study was conducted by representatives of the Rural
Development Foundation. Research was conducted in seven villages
namely: Hiddayath Nagar (360 families), Nagavillu New Errukkalampiddy
(1400 families), Palavi Fareedhabath (390 families), Y.M.M. A. Nagar
Rathmalayaya (1500 families), Thillayadi Al-Asqsa E.F. Camp (1750
families), Al Mina Sadamiyapuram (1600 families) and Aannaipullai Ottru
(550 families).
Most of the villages covered in this study had no proper drainage system
for waste water disposal, and around 35% of families do not have lavatory
facilities.
Ethnicity
A total of 84 women were interviewed in the sample survey all of whom
were from the Muslim community.
Table 1
Ethnicity by Age
Ethnicity
Muslim
Age 12-18
26 (30.9)
Age 19-40
37 (44.0)
Age 41-60
21 (25.0)
Total
84 (100.0)

Of the sample for the district, forty six women (55%) were married,
twenty three (27%) were unmarried, ten (12%) were widowed, while five
(6%) were divorced. Women were primarily engaged in household-related
activities or work available in the informal sector such as daily work as
housemaids in better off households, daily paid agricultural work (e.g.,
onion farms), sewing, preparing and selling food from the home.
75
Table 2
No
info,
0
Marital Status of the Interviewee (%)

Widowed,
4.4% Divorced,
0.0%
Unmarried,
26.9%
Married,
68.5%
Level of Education
The highest level of education achieved in this sample was among those
in the age group 12-18 years, while the lowest level of education achieved
was among those in the age group 41-60; fifteen (17.8%) were from the
12-18 year age group, fourteen (16.6%) from the 19-40 age group, and
two (2.3%) were from the 41-60 age group. A cumulative figure of thirty
one women (36.9%) from all age groups had up to a secondary-level
education.
Table 3
Level of Education.
Education Level
35.7%
27.3%
19.0%
9.5%
3.5%
15-18
76
19-22
23-25
26-29
2.3%
30-33
2.3%
Above 33 Unmarried
NA
Age at Puberty
Of the total sample, 27% had reached puberty between the ages 9-12;
64% between the ages 13-15, and 29% between the ages 16-19 years.
Table 4
Age at Puberty
Age at
Puberty
9-12
13-15
16-19
NA
Total
12-18 %
5
20
0
1
26
Age
19-40 %
11
25
1
37
41-60
7
9
5
21
Total
23
54
6
1
84
%
27.3
64.2
7.1
1.1
100.0
Knowledge about Puberty

Of the sample, 63% of the sample had found out about puberty on their
own, while 26.1 % had learned about it from friends. There was little
reference to information being obtained through the school education
system. Several women spoke of their ability to obtained some knowledge
about reproductive health through the work of the organization
Population Services Lanka (PSL).
Table 5
From Whom
Mother
Grandmother
Sister
Friends
Own
NA
Total
12-18
3
0
1
7
15
0
26
Age
19-40
1
1
0
10
25
0
37
41-60
0
1
0
5
13
2
21
Total
4
2
1
22
53
2
84
%
4.7
2.3
1 1.1
26.1
63.0
2.3
100.05
77
Age at Marriage
My elder daughter was married at 16. Her husband left her
when she was 17 and she had one child. She was married
again to a man with a first wife and she is very unhappy.
My second daughter left her husband within a year of her
marriage because he sold all her jewellery and wasted the
dowry we gave her. My third daughter eloped and was later
married. All my daughters are tortured by their husbands and
their families, mainly for not bringing enough dowry. They
are verbally abused and beaten often. All their husbands
are without jobs. My sons did not allow their sisters to
acquire any skills and so they are unable to be self sufficient.
(48-year-old woman Case Study, Puttalam)
Table 6
Age at Marriage
Age at Marriage of the Interviewee (%)
35.7%
27.3%
19.0%
9.5%
3.5%
15-18
19-22
23-25
26-29
2.3%
30-33
2.3%
Above 33
Unmarried
NA
Of the sample, who had ever been married, 35.7% had got married
between the ages 15-18 and 9.5% between the ages 19-22. This
information indicates that the age at marriage in the Puttalam District
is much lower than in the other districts surveyed in this research. The
reasons may be due to cultural factors; the total sample in the district was
from the Muslim community which recognises minimum age of marriage
as twelve years.
78
Knowledge of Contraceptives
I was born in Mannar in 1986 and was displaced at the age of
four to Kalpitiya and lived in a refugee camp for five years. My
father is a tailor and my brother works for daily wages. When
the family had only one breadwinner we often went hungry. I
am still studying and am in the A/Level arts class. According
to our religion, customs and heritage, it is good to marry and
begin a family of our own. Family planning must be adhered
to by all since bearing more children causes complications and
difficulties. In order to maintain a healthy relationship and
mutual understanding between husband and wife one must not
plan on starting a family soon after marriage. I gained some
knowledge of family planning through newspapers, radio and
health education in school. Gaining reasonable education in this
subject is very important to all, since it is helpful to be prepared.
To gain knowledge we can approach the PSL organisation in
the hospital where they have posters, leaflets and booklets on
this subject. Apart from this we can inquire from midwives and
others at the information desks at health centres. When friends
get together we share relevant information with one another.
(19-year-old woman Case Study, Puttalam)
Table 7
Interviewees who Know About
Knowledge About Contraception
Contraception by their Age (%)
70.3%
52.4%
42.3%
Age 12-18
Age 19-40
Age 41-60
79
The table above indicates that there is a relatively high level (70.3%) of
knowledge on contraception among women. Of the thirty four women
who responded to the question as to how they had learned about
contraception, sixteen (42%) said they had obtained information from
non governmental health focussed organization, the Population Services
Lanka. Another 29.4% had learned about contraception from friends
and 11.7% from medical practioners while 5.8% had learned about
contraception from their spouses.
Age at First Live Birth

Of the sample, a relatively high number (63.5 %) were between the ages
15-22 at the time their first child was born; 13% were between the ages 2325 years of age, and 22% were over 26 years of age. This low age at first
live birth is closely linked to the low age at marriage found in this district.
Table 8
Age at First Live Birth of the Interviewee (%)
34.0%
29.5%
20.4%
13.6%
2.2%
15-18
19-22
23-25
26-29
30-33
Above 33
NA
Experience of Miscarriage
Information on experince miscarriage revealed that 7 (50%) of the 14
women had one miscarriage, while two women had had two, and four
women had suffered three miscarriages. Nine women had miscarriages
occurring in the first 3 months of their pregnancy. Eight women had been
in the age group 16-19 when they had had their first miscarriage. All the
women reported that they had sought medical advice.
80
Experience of
Miscarriage
Yes
No
NA
Total
Age
12-18
3
2
21
26
19-40
4
7
26
37
41-60
7
6
8
21
Total
14
15
55
84
%
16.6
17.8
65.4
100.0
Age at Menopause
Since I had menopause at 40 years, I have not wanted to
have sex with my husband, elders also told me that I should
not have sex. My husband doesnt like this. So he now goes
to Jaffna and comes home only once in about three months
and gives us only about Rs. 2000 to 3,000 to manage. (Ms.
ARJ, 48 years, Puttalam)
Table 9
Age at Menopause
Age at
Menopause
25-30
31-35
36-40
41-45
46-50
50-55
NA
Total
12-18
0
0
0
0
0
0
26
26
Age
19-40
0
0
0
0
0
0
37
37
41-60
1
1
5
4
1
2
7
21
Total
1
1
5
4
1
2
70
84
Fourteen women in the age category 41-60 years had reported to have
reached menopause; thirteen of them had prior awareness of this life
change.
81
Domestic Violence
Of the sample, 67.8% declared that they had been subjected to violence.
Of this number, 28% who had experienced violence were between the
ages 12-18, 49% were between the ages 19-40, and 22% were between
the ages 41-60.
Most domestic violence had been perpetrated by the spouse for reasons
ranging from drunkardness, drug addiction, and financial problems.
Mothers were reported to be the next highest instigator of violence
as punishment for socially unacceptable behaviour such as having
unauthorized love affairs, marrying out of caste, and moving around freely
with others. Fathers also were found to perpetrate domestic violence as a
result of alcoholism, and financial problems.
Of those married women who declared that they had been subjected to
domestic violence by their spouses, most reported that this had occurred
during the first three years of marriage.
Table 10 Interviewees who have
Experienced
Domestic
ViolenceDomestic Violence
by their Age (%)
75.7%
61.9%
61.5%
Age 12-18
82
Age 19-40
Age 41-60
Location of Child birth

During my first preganancy I had severe pain and a blood clot
came out. I did not take any treatment for it and after fifteen
days I started bleeding again. We visited Jaffna and met a person
who does charms for evil spirits. He cast a charm on a piece
of brass and tied it on my wrist. He also cast a charm on some
water and sprayed it on my face. The bleeding stopped then.
(Ms. ISU, 62 years - Case Study, Puttalam)
In the Puttalam district, 11.6% of childbirths of women interviewed
had taken place in their homes compared to 88.3% in hospital. The total
sample was with women from the Muslim community.
While most women have sought government health services for the birth
of their children, it is important to note that traditional midwives play an
important role among these communities.
Age Group
and
Number of
Respondents
Home
Sub total
% of Total
Which
Child
1
2
3
4
5
12-18
19-40
41-60
Total
3
(7%)
26
(57%)
17
(37)
46
(100%)
0
0
1
1
0
0
1
3
1.9
3
4
5
1
4
15
9.7
4
3
5
1
5
18
11.6
Ethnicity
Table 11
Location of Childbirth by Number and Order of Childbirths
MUSLIM
83
Hospital
Sub total
% of Total
Total
Which
Child
1
2
3
4
5
1
1
0.6
27
21
16
8
6
78
50.6
14
14
8
11
10
57
37.0
81
72
42
35
24
19
16
136
88.3
154
100%
MUSLIM
MUSLIM
Pregnancy During Period of Conflict

I was displaced from Jaffna in 1990 and have been living in
Puttalam since then. I was stopped from attending school
when I attained age at 10 years. My mother used to go many
kilometres from home to collect oysters from the sea shore
and I would be left with my aunt and I had to help take care
of her ten children. When she had no work, my mother would
make hoppers and my brothers would sell them. I married
following a love affair and so our parents disapproved and we
had to undergo much economic hardship as my husband did
not have a regular job. We have seven children. I lost two
children soon after birth, one in three days and the other in
six months. We couldnt afford to give our children a proper
schooling. I thought of educating them further but this was
not possible when we were displaced in 1990. My youngest son
was in Grade 8 then and had to stop his education. In 1990
when we were displaced my husband was arrested by the army
and held in different jails. I visited him once a month with my
infant son and his brother. (Ms. ARJ, 48 years, Puttalam)
84
Table 12
Pregnancies during Conflict Years: Number and Order of Childbirths
Age Group and Number
of Respondents
Before
Which
Child
1
2
3
4
5
12-18
1
(3%)
41-60
16
(39%)
Total
41
(100%)
4
4
3
1
12
8.5
14
13
8
7
6
48
34.2
18
17
11
8
6
60
42.8
3
3
3
2
2
13
9.2
2
2
4
2
4
14
10.0
5
5
7
4
6
27
19.2
1
-
19
13
8
4
4
2
2
20
13
8
6
6
Sub Total
% of Total
1
0.7
48
34.2
4
2.8
Total
73
66
53
37.8
140
(100%)
Sub Total
% of Total
During
Sub total
% of Total
After CFA
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
19-40
24
(59%)
0
-
Of the forty one women who responded to this question, the most
number of women who had been pregnant during the time of active
conflict were from the age group 19-40.
85
In the Puttalam District, 42.8% of childbirths of interviewees had taken

place before the onset of the conflict, and 19.2% had taken place during
the period of active conflict. 37.8% of childbirths had taken place during
the period after the signing of the CFA.
86
3.2 Mannar District
Due to the fact that the Department of Census and Statistics has not been
able to conduct comprehensive population census surveys in the North
and the East, including Mannar District since 1981, there is no recent
information available in these areas during the period of this research.
The WMC research survey on womens perceptions and experience of
reproductive health and violence against women was carried out by the
Mannar Womens Development Federation (MWDF). The research was
carried out in five villages: Tharapuram (population 444), Shanthipuram
(1400), Marunkapity (417), Pesalai (725) and Parikorikandal (165). Most
of the women were engaged in informal sector activities such as farm
labour, cooking and selling food, fishing and related activities such as
cleaning nets, drying fish.
A total number of eighty nine women from these villages were interviewed.
85% of them were from the Tamil community (Christians and Hindus)
and 13% were from the Muslim community. 1% of the sample were from
the Sinhala community.
87
Ethnicity
The sample from Mannar represented the broad ethnic distribution in
the district.
Table 1
Ethnicity of Interviewees
Ethnicity
Muslim
Sinhala
Tamil
Total
12-18
1
0
7
8
%
13
0
87
100
Age
19-40
% 41-60
7
12
4
1
2
0
51
86 18
59
100 22
% Total
18 12
0 1
82 76
100 89
%
13
1
85
100
Level of Education
As the table below indicates, a significant number (41.5%) of the
sample had received formal education only up to Grade 8; most
of these women were those in the age categories 19-40 and 41-60.
This could be related to the impact of conflict in the area, which
disrupted access to schooling for the women in this age groups.
Table 2
Level of Education
Education Level of the Interviewee (%)

40.4%
25.8%
14.6%
12.3%
5.6%
1.1%
None
88
Grade 1-5 Grade 6-8 Grade 9-10 O/L Passed Grade 11- A/L Passed Higher
No
12
Education response
The highest level of education was found to have been achieved by those
in the age group 19-40, while the lowest level of education (Grade 5 or
below) was found among those in the age group 41-60.
Of the total eighty nine women interviewed, 40% had studied up to
grades 9-10, 25% up to grades 11-12, 15% between grades 1-5 and, 12%
between grades 6-8.

Table 3
No
info,
0

Widowed,
4.4% Divorced,
0.0%
Unmarried,
26.9%
Married,
68.5%
The majority of women in the sample (63.5%) were married. There was
a relatively high number of unmarried women in the age category 19-40
years.
Age at Puberty
Of the total eighty nine women interviewed, 73% had reached puberty
between the ages 13-15; 17% had reached puberty between 9-12 years,
and 9% between the ages 16-19.
89
Table 4
Age at Puberty
Age at Puberty
Age
2-18
19-40
41-60
Total
9-12
2
25 12
20 1
6 15
16.8
13-15
6
75 40
68 19
86 65
73.0
16-19
0
0
6
9 2
9 8
8.9
Total
8
100 59* 100 22
100 89 100.0
* Age at puberty of one woman in this age group was not recorded.

Sixty five women who had responded to this question, 65% had not been
aware of puberty at the age of getting their first menses; 11% had learned
about puberty from their mothers, 12% from their friends, 6% from their
grandmothers, and 3% from their sisters.
Table 5
From Whom
Mother
Grandmother
Sister
Friends
Own
NA
Total
12-18
1
1
0
0
5
1
8
Age
19-40
5
3
2
7
27
15
44
41-60
1
0
0
1
12
8
14
Total
7
4
2
8
44
24
89
%
8
4
2
9
49
27
100
Age at Marriage
Compared with the data from the other districts, the data from Mannar
sample indicated a relatively high age at marriage. This may account for
the lower proportion of unmarried women noted in Table 3.
90
Table 6
Age at Marriage

26.9%
19.1%
21.3%
14.6%
11.2%
15-18
19-22
23-25
26-29
3.3%
3.3%
30-33
Above 33
Unmarried
NA
Of eighty nine women interviewed 33.8% had been married between the
ages of 15-22; 21.3% had been married between the ages 23-25 and 3.3%
had been married above the age of 30.
Knowledge about Contraception

I havent got my monthly menstruation since I delivered my
second child. Three months after the birth I took the injection
and gained weight as a result. I have stopped the injection for
the last one year. I thought I was pregnant and went for a test
to Population Services Lanka and they said I was not pregnant.
They wanted me to do a blood test but I couldnt afford to
do it privately so I went to the General Hospital. At the time
the facility was not available at the hospital. I went again last
month. If there are about ten patients, then they collect the
blood and send it to Colombo for testing. They wanted me to
come in April for the blood test. I have gained weight and find
it difficult even to walk. (CM, 28 years Case Study, Mannar)
I got married at 16. My first child was born when I was 17. I
did not know about contraception methods then. After this
birth my mother told me about natural contraception methods.
I had some idea of other methods but my mother did not allow
91
me to use them. She feared that I would have some sickness by

using them. The natural method did not work for me because
my periods are irregular. As a result my second child was born
after two years. After that I started using the pill. I didnt
listen to my mother, I went to PSL classes. PSL brought the
pills to our homes for sale. I started gaining weight and my
periods were not regular so I stopped the pill and in the last
two years have been following the natural method. When I
had problems with the pill I tried to speak to the PSL doctor
but he was male. It is absolutely essential that PSL has female
doctors; we could have spoken more freely. They charge us a
fee which is less than private clinics. They used to offer a free
service in the camps but that has stopped now. (DJJ, 27 years
Case Study, Mannar)
It is evident that where both government and nongovernment health
service delivery operate, women are more likely to be aware of family
planning methods as the table below shows.
Table Interviewees
7
who Know About

64.4%
77.3%
12.5%
Age 12-18
Age 19-40
Age 41-60
Most women (35%) had learned about contraception from a medical

practitioner. The other sources of information were from friends (13%),
Population Services Lanka (11%), mother (4%) and spouse (2%).
92
When I was pregnant with the fourth child after three girls
my husband said jokingly that if it was a girl he would kill
the child. I didnt mind the three girls. We did not want
to have children after the third but we both thought after
sometime that we must have another child because we
need to have at least one boy. I happened to read an article
translated from a Chinese paper where they said that within
a particular period if you had sex you could have a boy. I
really believed it and told my husband about it and he agreed.
After the third child was born my grandmother said that if
I lay down on my left side after sex it would be a boy. I
practiced that too along with what was said in the Chinese
paper. We were very happy when the fourth baby was a boy.
At the Mannar hospital if we ask about family planning
they give us an answer. There are male doctors and female
doctors but the female doctors are Sinhala speaking, so we
have a communication problem. (MC, 45 years - Case Study,
Mannar)
It is important to note that sociocultural practices and beliefs impact
strongly on womens ability to make decisions regarding the number and
spacing of the children they wish to have, as is illustrated from the above
case study.

Of sixty two women who had given birth in the sample, 30% had been
between 23-25 years of age at the birth of their first child; 37% had been
between 15-22, and 12% over 30.
93
Table 8
30.3%
19.1%
20.2%
14.6%
7.8%
5.6%
2.2%
15-18
19-22
23-25
26-29
30-33
Above 33
NA
Few women reported to have undergone miscarriage of their pregnancies
in this sample. Four out of the Seven women reporting miscarriage
were from the age category 41-60. Three of these women had suffered
miscarriage in the 4-6 months of pregnancy, while this was also the case
for two women from the age category 41-60 years. All the women had
sought medical advice either from a midwife or doctor.
Table 9
Experience of
Miscarriage
Yes
No
NA
Total
94
12-18
0
0
8
8
Age
19-40
4
10
45
59
41-60
3
5
14
22
Total
7
15
67
89
%
7.8
16.8
75.2
100.0
Age at Menopause
Most women had undergone menopause after the age of 40.
Table 9
Age at Menopause
Age at Menopause
12-18
0
0
0
8
8
41-45
46-50
50-55
NA
Total
Age
19-40
0
0
0
59
59
41-60
4
4
1
13
22
Total
4
4
1
80
89
Domestic Violence
The main perpetrator of domestic violence was reported to have been the
spouse. The most common reasons were cited as alcoholism, suspicion
and drug addiction. The father of the interviewee was also reported to
have been responsible for violence in the home.
Table 10
Interviewees
Domestic
Violence who have Experienced
Domestic Violence by their Age (%)

16.9%
18.2%
0.0%
Age 12-18
Age 19-40
Age 41-60
95
Location of Childbirth
The research brought out the fact that while most childbirths took place
in hospitals, there were a number which took place in the home. In the
Mannar District, the number of home births reported in this study was
7.2% compared to 92.7% in hospital. Most women had given birth to
their children in hospitals.
Table 11
Location of Childbirth by Number and Order of Childbirth
Age Group and
Number of
Respondents
Home
Sub total
% of Total
Hospital
Subtotal
% of Total
Total No.
Childbirths
96
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
12-18
19-40
41-60
Total
40
21
61
0
0
1
2
1
1
1
6
3.6
2
3
1
6
3.6
3
5
1
2
1
12
7.2
39
28
16
7
2
92
19
17
14
8
3
61
58
45
30
15
5
153
0
0
55.7
98
36.9
67
92.7
165
(100.0%)
Pregnancies during Conflict Years

During the war we had problems taking pregnant mothers to
hospitals if it was a caesarean case. We had to inform the
army and it was through their helicopter services that patients
were transported to Anuradhapura hospital. One relative was
allowed to accompany the patient. At the hospital language
was a problem because most of the staff were Sinhalese.
Sometimes there were Tamil or Muslim staff. (MSP, 42 - Case
Study, Mannar)
At the time of the war there was only one doctor at the Mannar
hospital. If he went on leave there were no doctors. Deliveries
were done by the midwife. If a caesarean had to be done
patients had to be taken to Vavuniya via Madu. There was
no access to the Mannar District hospital as the bridge was
blasted during the war. During the war it was an attendant
who used to give injections to patients. There were no clinics
and there was a shortage of medicines. (KK, 27 years - Case
Study, Mannar)
The sterilization method of contracpeiton was available before
the war but we did not have the facility during the war years.
It has been introduced again now. (MSP, 42 Years - Case Study,
Mannar)
Women who had been pregnant during the years of conflict pointed
out specific difficulties they faced in accessing reproductive health
services in the district. These ranged from nonavailability of skilled
medical personnel, non accessibility of hospitals and nonavailability of
contraceptives. As the table below indicates, the Mannar sample included
a high proportion of women who had been pregnant during the years of
conflict in the district.
97
Table 12
Pregnancies during Conflict Years by Number and Order of Child birth
Age Group and Number
of Respondents
Before
Sub Total
During
Sub total
After
Sub Total
Total
12-18
0
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
19-40
38
(68%)
41-60
18
(32%)
Total
56
(100%)
0
0
0
0
0
0
3
2
5
11
9
6
4
2
32
14
11
6
4
2
37 (25%)
0
0
0
0
0
0
25
23
9
3
1
61
7
8
5
1
2
32
31
14
4
3
84 (56%)
0
0
0
0
0
10
3
7
5
2
0
0
0
1
0
10
3
7
6
2
0
0
27
93
28 (18.7%)
149 (100%)
* Information on 16 childbirths not available.

Of the fifty six women who responded to the question, 56% had been
pregnant during the years of the ethnic conflict, 25% before the conflict
affected their area, and 18.7% during the period after the signing of the
CFA.
98
3.3 Polonnaruwa District

Border Villages
The Polonnaruwa District is noted to have a relatively high population in

poverty compared to national level data. According to the Department
of Census and Statistics in 2002, the share of poorest women in terms
of national consumption was 8.8 compared to 6.2 at the national level.51
The under-five mortality rate in Polonnaruwa in 2002 was 16.1 for
females and 17.6 for males.52 The comparative national-level figures
for the reference year were: 12.0 for females and 14.9 for males. It is
recorded that in the Polonnaruwa District, infant mortality rates for the
year 2002 were: 16.1 for females and 17.6 for males. The comparative
national-level figures for the reference period were: 10.2 for females and
51. Department of Census and Statistics (2005). Household income and its distriburtion
are estimated from household surveys. Household income is adjusted for household
size to provide a more consistent measure of per capita income for consumption.
Household income is divided by the number of people in the household to establish
income per person which is ranked by income. The income of the bottom fifth is
expressed as a percentage of aggregate income. Selected Millenium Development Goals
(MDGs) Indicators, Colombo.
52. Ibid. Child mortality rate is defined as the probability (expressed as a rate per 1000
live births) of a child born in a specified year dying before reaching the age of five is
subjected ti current age-specific mortality rates.
99
12.9 for males.53 The national-level maternal mortality rate was 42.2 in
1991 and 27.5 in 2002. However, these figures are not recorded for the
Polonnaruwa district.54
Polonnaruwa Background
The Polonnaruwa study was carried out by two researchers affiliated to
the Polonnaruwa Womens District Committee.
These villages have an ethnic mix of Sinhalese, Tamils and Muslims. Some
of them are old established villages, purana gam, while others are fairly
new village settlements established under the Mahaweli Authority with
mainly Sinhala settlers. During the years of conflict a number of villages
in this area came under LTTE and state attacks and counterattack. A
number of village massacres took place in villages such as Bo-Atta. Such
attacks led to mistrust and hostility among Sinhala, Tamil and Muslim
villagers who had traditionally intermarried and co-existed amicably. The
establishment of home guards, mostly Sinhalese and Muslims, to protect
Sinhala and Muslim villages further exacerbated the problem and provided
the impetus for more LTTE led attacks and counterattacks. These villages
are among the poorest and most marginalized in the conflict zone and
receive insufficient attention from policy makers and policy implementers.
Research Locations
Bo-Aththa. This border village which was set up under the Mahaweli
project has over 250 families comprising both Sinhalese and Tamils. The
villagers are mainly cultivators; few are engaged in government or private
sector employment. While there are some female-headed households,
most households are headed by men.
53 bid. Infant mortality rate is the probability (expressed as a rate per 1,000 live births)
of a child born in a specified year dying before reaching the age of one if subjected
to current age-specific mortality rates.
54 Ibid. Maternal death is the death of a woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the duration and the site of the pregnancy,
from any cause related to or aggravated by the pregnancy or its management, but not
from accidental or incidental causes.
100
There is a strong practice of arranged marriage in this village; often this is

among residents of the village itself. Early marriage was also noted with
frequent reports of marital disputes and separations. The government
health services form the main source of healthcare. However, there were
reports of lack of adequate access to safe drinking water and sanitation
facilities. It was reported that NGOs such as Sarvodaya have provided
toilet facilities to some households. Most families live in wattle and daub
houses or houses with cadjan roofs.
Monaratanna: This is also a border village which had been setup under
the Mahaweli project. Approximately 300 families comprising Sinhalese,
Muslims and Tamils live in this village. The total population is between
700 and 800 persons. Most villagers are engaged in cultivation. Few are
engaged in government or private sector employment. However, since
the economic return from their livelihoods is low, there is a pattern of
people leaving the village to seek better employment. As with Bo-aththa
there is a pattern of arranged marriage as well as early marriage. The
pattern of early marriage has an impact on the continuing education of
youth in the area.
Mangulpokuna: This village set up under the Mahaweli project has
approximately 200 families comprising Sinhalese and Tamils. The
population of the village is about 500. The main source of income is
paddy cultivation; another is daily paid unskilled labour. Few have found
employment in the government sector.
The village faces a critical shortage of safe drinking water particularly
in the dry season. The ethnic mix of the population has seen marriages
between Sinhalese and Tamils. The village has a pattern of early marriage
with a significant break up or separation of couples soon after. There is
a presence of Sri Lankan armed forces as a consequence of the ethnic
conflict. This has resulted in marriages between soldiers and young
women, as well as reports of pregnancies outside of marriage. School
attendance is reportedly low, with many opting to seek daily paid work to
help their families.
Maithreegama: This is another village set up under the Mahaweli project
at the border of the eastern districts. The village saw much damage and
101
destruction during the period of active military confrontation between

the Sri Lankan armed forces and the LTTE. There are approximately
300 families with a population of approximately 700 persons who are
Sinhalese. Most men and women are engaged in cultivation as well as in
daily wage labour. Few have found employment in the government sector
or in private enterprises. It is reported that Tamil and Muslim labourers
come in to this village to seek daily wage work.
There is tendency for young children to drop out of school and for youth
to seek early marriage. There is reportedly a shortage of teachers in the
villages which contributes to children not attending school on a regular
basis. Access to safe drinking water is a recurrent problem. The village
has a pattern of early marriage with a significant break up or separation
of couples soon after.
Malvila: The border village was set up under the Mahaweli project and has
a population of approximately 500. It is a predominantly Sinhalese village.
There are several Muslim villages in the vicinity. The main occupation
is paddy cultivation. A few people work in the government sector or in
private enterprises.
Arranged marriage tends to be common in the village. The village has
a pattern of early marriage with a significant break up or separation of
couples soon after. Many young women marry early with little or no
knowledge of married life. There is also a significant presence of Sri
Lankan armed forces as well as police.
There is reportedly poor attendance in school as young children tend to
seek income earning work.
Senapura: The border village was also set up under the Mahaweli
project. During the time of active military confrontation between the
Sri Lanka armed forces and the LTTE, the village suffered much damage
and destruction. There are more than 500 families in the village who are
Muslims.
The main occupation of men in the villagers is business, and for women
of is the migration overseas to work as housemaids in West Asian
countries. Hence, women are seen as an important factor in the economic
102
upliftment of their families. Safe drinking water is a problem; families

obtain water from wells, tube wells and open streams. The health services
available are inadequate.
Many young girls are given in marriage at an early age. Marriage partners
are sought from among the community itself either from within the
village or from elsewhere. There is a pattern of girls dropping out of
school early.
Katuwanvila
The village was set up under the Mahaweli project and comprises
approximately 500 Muslim families with a population of about 1,800.
The villagers engage in cultivation, business and unskilled labour, and
there is a pattern of women migrating overseas for employment.
There is reportedly low participation in schooling among young children,
while girls are taken out of school at an early age. Marriages are sought
from within the Muslim community, either in the village or from elsewhere.
The health services are inadequate, and there is a shortage of safe drinking
water and sanitary facilities.
Ethnicity
The ethnic balance of the interviewees reflects the multi-ethnic nature of
the population living in the border villages of the Polonnaruwa District.
Table 1
Ethnicity of Interviewees by Age
Ethnicity
Sinhala
Tamil
Muslim
NA
Total
12-18
10
3
5
1
19
Age
19-40
28
5
12
0
45
41-60
19
4
7
1
31
Total
57
12
24
2
95
%
60.0
12.6
25.2
2.1
100.0
103
Level of Education
I went to India in 1990 as a refugee when I was 14, due to
the conflict and ensuing problems. I had to stop my studies
at Grade 6 due to the war. I did not continue my studies in
India because I did not want to study with younger students.
Now I dont have the time with two young children. I
returned from India in 1997. I went to the Middle East as a
housemaid and returned within a year. My promised salary
of 400 Riyads per month wasnt paid, but I was too scared
to go to the agent thinking he would send me back. I went
to the Police and returned to Sri Lanka. (RB Case Study,
Polonnaruwa)
Table 2
Level of Education by Age Group:
32.6%
28.4%
25.2%
8.4%
4.2%
1.0%
None
No
12
Education response
In the Polonnaruwa District border villages, it is evident that there is a

high dropout rate for girls. 53% of the sample had had formal schooling
only up to Grade 8 or below. Most of these women were from the age
cohorts 19-40 and 41-60.
Marital Status
Most of the interviewees (76.8%) were married. The unmarried women
were recorded to have been from the age categories 12-18 years and 1940 years.
104
Table 3
No
info, 0
Widowed, Divorced, 1.0%

7.3%
Unmarried,
14.7%
Married, 76.8%
In the study sample, there was a high representation of married and

ever married women compared to those who were unmarried. It is also
important to note that this corresponds with the data in the table below,
which shows that 54.3% of women in the sample had got married by
the time they were 18 years of age. A total of 88.8% of women had been
married by age 22.
Age at Puberty
A significant number of the sample had attained age between 9 and 12
years. 70% of the total sample had reached puberty by the time they were
15 years old.
Table 4
Age at Puberty
Age at
Puberty
9-12
13-15
16-19
Total
12-18 %
7
12
0
19
Age
19-40 %
12
27
6
45
41-60 %
6
22
3
31
Total
25
61
9
95
%
26.3
64.2
9.4
100.0
105

I was 13 years old when I attained age. My mother had told
me about it before so when I found out I told my mother. She
told me things like not to go out, and not to look at men. I
was bathed daily by my mother and also after 7 days according
to the practice of our religion, Islam. We had no money for
a celebration so we only performed the rituals. Now when a
girl attains age, even the neighbours dont know, there is no
celebration, no crackers are lit because of the LTTE troubles.
When I attained age I was not told anything about having
children. (SSSF, 44 - Case study, Polonnaruwa)
It is interesting to note that in the border villages of the Polonnaruwa
District, as indicated in the table below, mothers play a key role in
informing their daughters about puberty.
Table 5
From Whom
Mother
Grandmother
Sister
Aunt
Friends
Own
NA
Total
Age 12-18
14
1
1
2
0
0
1
19
Age 19-40
28
4
4
3
0
0
6
45
Age41-60
17
4
2
3
0
0
5
31
Total
59
9
7
8
0
0
12
95
Age at Marriage
When I was 15 my parents married me off although I did not
like to get married then. After a month I was pregnant, in
three months my husband left me. After a while I got pains
and my mother took me to hospital. I was in hospital for two
months and three days. Then they said I was going to have
106
twins and that I should be taken to a hospital in Anuradhapura

or Vavuniya. I was taken to Vavuniya. My mother got malaria
at this time and couldnt come to visit me. I gave birth to a
baby girl but no one came to see me. I drank only coffee. I
couldnt eat the food the other patients offered me. After six
days my brother came to see me and I was discharged. We
left after 12 noon. When we got to the town there was no
bus for us to return to our village. A bus came around 6 pm.
When we were in the bus two men asked me to give my baby
to them. I was very frightened. I told my brother to drop
me at the Kebithigollawa hospital stand so that I could stay
there overnight. The man who wanted my baby was with my
brother throughout the night. My brother came for me at 5
am and without waking the man we went home. I had a proper
meal only after seven days. I spent 1 - years very sadly.
(SSSF ,44 - Case study, Polonnaruwa)
The Polonnaruwa District data reveals a high rate of underage marriage,
which appears to be a practice in this impoverished area.
Table 6
Age at Marriage
46.3%
29.5%
14.7%
6.3%
15-18
19-22
23-25
2.1%
1.1%
26-29
30-33
Above 33
Unmarried
NA
107

Women had obtained knowledge about contraception from friends,
doctors and the organization Population Services Lanka.
Table 7
Interviewees who Know About

91.1%
64.5%
42.1%
Age 12-18
Age 19-40
Age 41-60
Age at First Birth

Reflecting the pattern of early marriage as seen in Table 6, 34.7% of
women delivered their first child between the ages of 15 and 19. Of this,
67% were from the age category 19-40.
Table 8
34.7%
29.4%
14.7%
15-19
108
20-24
16.8%
23-25
1.0%
2.1%
1.0%
26-29
30-33
Above 33
NA
Out of the sample, 14.7% had suffered at least one miscarriage. Of these,
eight had been in the first 3 months of the pregnancy while six had been
in the period between 4-6 months of pregnancy. All women reported that
they had sought medical treatment at hospitals or clinics.
Table 9
Experience of
Miscarriage
Yes
No
NA
Total
Age
12-18
19-40
41-60
1
2
16
19
7
8
30
45
6
12
13
31
Total
%
14
22
59
95
14.7
23.1
62.1
100.0
Age at Menopause
Women over the age category 41-45 years reported that they had
experienced menopause from their early 50s.
Table 10
Age at Menopause
Age at Menopause
Age 25-30
31-35
36-40
41-45
46-50
51-55
NA
Total
12-18
0
0
0
0
0
0
19
19
Age
19-40
0
0
0
0
0
0
45
45
41-60
0
0
1
0
0
15
15
31
Total
0
0
1
0
0
15
79
95
109
Domestic Violence
In response to the question on whether the interviewee had been subject
to domestic violence, twenty nine women (30.5%) answered that they
had. Of these, 82.7% were between 19-60 years of age. The persons who
had inflicted violence on them were: their mother in their youth for being
disobedient or not fulfilling household tasks, and the spouse as a result
of drunkardness.
Table 10
Domestic Violence
Domestic
Violence
Yes
No
NA
Total
12-18
5
8
6
19
Age
19-40
11
23
11
45
41-60
13
15
3
31
Total
29
46
20
95
%
30.5
48.4
21.0
100.0
Pregnancy during Conflict Period.

I remember when I was married and expecting my first baby, we used to
hear sounds of gunshots. Then we went into the forest after blowing out
the lamps in the house. When the shooting died down and the army told
us it was safe we returned home. I remember one occasion when I was
pregnant I had to climb an ehala tree for safety. But none of us was hurt
and the baby was born alright. None of my family was hurt by the LTTE.
There is a clinic at Senapura but we have no health officials visiting the
village even now, and we dont have a midwife either. During the war
there was no vehicle to take a pregnant woman to hospital. They had to
go in a tractor. Now there are three wheelers and we can get to hospital
quickly. (SK - Case Study, Polonnaruwa)
110
Table 11
Pregnancy During the Conflict Period: Number and Order of Child Births
Age Group and
Number of
Respondents
Before
Sub Total
% of Total
During
Sub total
% of Total
After the CFA
Sub Total
% of Total
Total
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
12-18
19-40
41-60
Total
32
20
55
1
1
0.5
11
8
4
1
24
14.2
23
13
8
3
2
49
29.1
35
21
12
4
2
74
44.0
47.2
28.3
16.2
5.4
2.7
100.0
16
13
8
4
5
46
27.3
3
4
6
4
5
22
13.0
19
17
14
8
10
68
40.4
27.4
25.0
20.5
11.7
14.7
100.0
2
-
11
5
3
3
2
13
5
3
3
2
50.0
19.2
11.5
11.5
7.6
24
100.0
94
71
26
15.4
168
100.0
40.4% of childbirths had taken place during the time of active conflict.
44.0% had been born before the onset of the conflict, and 15.4% after
the signing of the CFA.
111
From the responses of the women, it is clear that while 63.8% had
delivered their children in hospital, a significant number, 35.5%, had
delivered their babies at home. Home birth was highest among the women
from the Muslim community; cultural practice was cited as a possible
reason for this. There was one woman who had delivered her baby in a
vehicle on the way to the hospital during a military encounter between the
Sri Lankan army and the LTTE.
Table 12
Location Where Child was Born by Number and Order of Childbirth
Age Group
Home
Sub Total
% of Total
Hospital
Sub Total
% of Total
Other
Sub Total
Total
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
12-18
19-40
41-60
Total
8
5
1
5
3
22
11
9
7
6
4
37
58
64
88
55
57
100
18
14
8
11
7
58
35.5
3
-
29
18
14
3
3
15
9
8
2
-
32
33
36
40
-
47
27
22
5
3
67
34
0
3
1
1
90
0
72
* Four women did not respond to this question.

112
104
63.8
-
1
0
163
3.4 Batticaloa District
The Batticaloa reseach was undertaken with the assistance of the Suriya
Womens Development Centre.
Batticaloa District Background
Batticaloa is one of four districts in the research for which there is limited
national-level data, given that the ethnic conflict restricted the areas in
which censes could be carried out over the last 20 years. However, some
information is available through more recent data from the Department
of Census and Statistics. Accordingly, it is found that in 2002, the under
5 mortality rate was17.5 for females and 23.6 for males. The comparative
national level figures were as follows: 12.0 for females and 14.9 for
males.55 The infant mortality rate is recorded as 14.4 for females and 17.4
for males, while the corresponding national rate was 10.2 for females and
55. Department of Census and Statistics (2005). Op cit.
113
12.9 for males.56 Maternal mortality for this reference period was 32.9
for Batticaloa; at the national level it was 27.5.57 These statistics indicate
that in terms of access to healthcare, the Batticaloa District is clearly
disadvantaged compared to other parts of the country.
As the conflict grew in intensity Batticaloa experienced frequent cordon
and search operations, arrests and detentions. There were also increasing
instances of torture and ill treatment of young persons, mostly men, when
in detention, and a significant number of disappearances also occurred
in the region. With the withdrawal of the IPKF in 1990 Batticaloa was
severely affected by the break out of Eelam War II. As fighting intensified
between the state armed forces and the LTTE for control of territory, a
large percentage of the inhabitants of Batticaloa were displaced in 1991
and sought refuge in the south, particularly Colombo, where the majority
of them lived in camps for the displaced. By 1993 these camps were
arbitrarily shut down by the state and people returned, some to their
own homes and others to resettlements or welfare centres. Batticaloa
also experienced a series of massacres or large-scale disappearances in
the early 1990s, infamous among them the disappearances of over 150
displaced who were sheltering in the premises of the Eastern University
at Vandaramoolai, Kathankudi, Eravur and Oddamavadi Muslim
enclaves following the mosque massacres at Eravur and Kathankudy
in the early 1990s. This period also saw interethnic tension between
Muslims and Tamils. In the last decade i.e. since the mid 1990s, there has
been an increase in the number of women from the Batticaloa District,
in particular from Oddamavadi, seeking employment in West Asia.
56 Ibid. Child mortality rate is defined as the probability (expressed as a rate per 1000
live births) of a child born in a specified year dying before reaching the age of five is
subjected ti current age-specific mortality rates.
57 Ibid. Maternal death is the death of a woman while pregnant or within 42 days of
termination of pregnancy irrespective of the duration and the site of the pregnancy,
from any cause related to or aggravated by the pregnancy or its management, but not
froom accidental or incidental causes.
114
Batticaloa District Research Locations

The research was carried out in several divisions in the Batticaloa District.
Complete interviews were received from 76 out of a total of 78 women
interviewed for this research. The research was carried out in several
Grama Niladhari (GN) divisions in the district.
GN Division Valaichchenai: Total population was reported to be 28,460
persons comprising 7,227 families. The number of females was 13,967 and
the number of males 14,493. The ethnic distribution of the population
was: Muslim 27,569, Tamil 796 and Sinhalese 46. The main occupation
was trade and business.
GN Division Ottamavady: Total population was 27,043 persons
comprising 6,953 families. The female population was 14,639 while the
male population was 14,404. The ethnic distribution of was: Muslim
26,841, Tamil 186 and Sinhalese 16. The main occupations were fishing,
trade and business.
GN Division Jayanthiyaya: The total population was 28,460 comprising
7,227 families. The female population was 13,097 while the male population
was 14,493. The number of female-headed households was 2,426. The
ethnic distribution was: Muslim 27,569, Tamil 796 and Sinhalese 46. The
main occupation was farming.
GN Division Eravur: The total population was 1,270 comprising 326
families. The female population was 654 while the male population was
616. The ethnic distribution was: Muslim 1,270. The main occupations
were farming, mat weaving, making pots and trade in cashew.
GN Division Palamunai: The total population was 30,204 comprising
12,083 families. The female population was 15,302 while the male
population was 14,809. The ethnic distribution was: Muslim 30,204. The
main occupations were fishing and weaving mats.
GN Division Kaththakudy: The total population was 40,421 comprising
10,773 families. The female population was 20,036 while the male
population was 20,085. The ethnic distribution was: Muslim 40,421. The
main occupations were trade and business and mat weaving.
115
Divisional Secretariat Manmunai North: The total population was 78,963

comprising 19,334 families. The female population was 40,722 while the
male population was 38,241. The ethnic distribution was: Tamil 91.8%,
Muslim 5.1%, Sinhalese 0.2% and Burgher 2.8%.
GN Division Kallady Veloor: The total population was 2,265 comprising
648 families. The female population was 1,117 while the male population
was 1,148. The number of female-headed households was 92. The ethnic
distribution was: Tamil 2,259 and Sinhalese 6. The women in the village
who have access to or own property remain in the village upon marriage,
while others move to the village of the spouse.
GN Division Thiruchendhur: The total population was 2,758 comprising
was 1,384. The number of female-headed households was 54. The ethnic
distribution was: Tamil 2,476, Sinhalese 2, and Burgher 10.
GN Division Thiramadu: The total population was 1,456 comprising
358 families. The female population was 748 while the male population
was 708. The number of female-headed households was 31. The ethnic
GN Division Periya Uppodai: The total population was 4,609 comprising
was 2,395. The number of female headed-households was 131. The ethnic
Divisional Secretariat Manmunai South and Eravil Pattu: The total
population was 56,823 comprising 14,787 families. The female population
was 29,082 while the male population was 27,741. The ethnic distribution
was: Tamil 99.9%, Muslim 2, Sinhalese 51, and others 14.
GN Division Kaluwanchikudy North: The total population was reported
to be 1,099 comprising 308 families. The female population was 599 while
the male population was 500. The number of female-headed households
was 108.
116
GN Division Kaluwanchikudy South : The total population was reported

to be 2,051 comprising 575 families. The female population was 1,067
while the male population was 984. The number of female-headed
households was 87.
GN Division Kaluwanchikudy North 1: The total population was
reported to be 1,527 comprising 366 families. The female population was
826 while the male population was 701. The number of female-headed
households was 66.
Divisional Secretariat Porathivu Pattu: The total population was reported
to be 3,621 comprising 1,030 families. The female population was 1,881
while the male population was1,740. The ethnic distribution was: Tamil
100%.
GN Division Mandur 3: The total population was reported to be 1,086
comprising 292 families. The female population was 552 while the male
population was 534. The number of female-headed households was 174.
GN Division Mandur Kottamunai: The total population was reported to
be 937 comprising 273 families. The female population was 490 while the
male population was 447.
GN Division Mandur 1 and 2: The total population was 771 comprising
was 357. The number of female-headed households was 40.
GN Division Mandur South: The total population was 826 comprising
Divisional Secretariat Manmunai South West: The total population was
4,304 comprising 1,041 families. The female population was 2,266 while
the male population was 2,038. The ethnic breakdown was 100% Tamil.
GN DivisionMunaikadu East: The total population was 874 comprising
117
GN DivisionMunaikadu West: The total population was 1,172 comprising

GN Division Munaikadu South: The total population was 1,096
GN Division Munaikadu North: The total population was 1,162
Divisional Secretariat Manmunaipattu (Araiyampathy): The total
population was 29,448 comprising 7,963 families. The female population
was 15,127 while the male population was 14,321. The ethnic breakdown
of the area was: Tamil 75.7%, Muslim 24.3%.
GN DivisionThalankudah: The total population was 1,142 comprising
was 546. The number of female-headed households was 77. The main
sources of income was from farming, fishing, manual work. Few are
employed in the government sector.
Munaikkadu, Mandoor: The main source of income is from farming and
secondly employment in the government sector. Small-scale vegetable
cultivation, home gardening, animal husbandry (cattle).
118
Research Findings
Ethnicity
The Batticaloa sample was representative of the majority ethnic

populations in the district.
Table 1
Ethnicity by Age of Interviewees
Ethnicity
Muslim
Tamil
NA
Total
Age
19-40
21
20
0
41
12-18
10
4
0
14
41-60
14
7
0
21
Total
45
31
0
76
%
59.2
40.7
0
100.0
Level of Education
The table below indicates that the highest participation and comparative
educational achievement has been among women in the age cohort 1940, indicating a higher level of education in the years pre-conflict and in
the early period of the conflict when the district was less affected by its
ravages.
Table 2
Level of Education by Age Group of theIinterviewees
35.5%
19.7%
15.7%
11.8%
9.2%
6.5%
1.3%
None
No
12
Education response
119
Marital Status
While 60.5% of the sample were married it is interesting to note that
fourteen (58%) of the 24 unmarried women were from the age group
19-40.
Table 3
Marital Status by Age
NoMarital Status of the Interviewee (%)
info, 0
Divorced,
Widowed, 1.3%
6.5%
Unmarried,
31.5%
Married,
60.5%
Age at Puberty
The above data shows that most women reached puberty between the
ages 13-15, although a significantly high 40.5% reached it between the
ages of 9 and 12. Reflecting the national average, 53.1% of women had
reached puberty by the age of 15.
Table 4
Age at Puberty by Age Group of Interviewees
Age at Puberty
9-12 years
13-15
16-19
NA
Total
120
12-18
7
7
0
0
14
Age
19-40
13
25
1
2
39
41-60
10
11
0
2
21
Total
30
43
1
2
76
%
40.5
58.1
1.3
2.6
100.0

The data below indicates that most women had no prior knowledge
about puberty at the time of getting their first menses. The role played
by mothers is less significant compared with data from some of the other
districts.
Table 5
Knowledge about Puberty (Percentage)
From whom
Friends
Grandmother
Mother
Found out herself
Sister
Own friends and others
Not Available
%
9
1.3
4
70
2.6
2.6
Age at Marriage
I was in Grade 4 when I attained age and my mother stopped
me from going to school after that. Since I married very young
(at 16 years) my husband took all the decisions regarding the
family. I do that now in consultation with the elder children.
However, my husband and I decided together about spacing
children, because I did not want to give birth every year and
also because it would be difficult to bring up the children. I had
no training nor did I learn any other skill. I am now a widow
with four children. I weave mats and sell a mat to a trader at
Rs.50/-. (Ms.T, 38 - Case Study, Batticaloa)

121
Table 6
Age at Marriage by Age Group of Interviewees
31.5%
21.0%
18.4%
17.1%
3.9%
15-18
19-22
23-25
26-29
6.5%
1.3%
30-33
Above 33
Unmarried
NA
As the above table indicates, most women got married between the ages
19-25, although 30% of the sample were married between 15 and 18,
indicating a significant percentage of early marriage.

I knew about reproductive health from friends and from the
village midwives. I also gained knowledge by listening to the
Ask Your Doctor radio programme. I have obtained advice
about birth problems from doctors at hospitals. Most of the
doctors are male, I did not talk to them about birth control.
I got that advice from the midwife. I have used the pill, the
injection, and my husband has used a condom. The midwife
and my husband influenced me in the selection of birth control
methods. (Ms.T, 38 - Case Study, Batticaloa)
I live in a backward village with no transport facilities. My
mother lives with me and looks after the children. I have three
sisters and two brothers, they all dropped out of school early.
I have six daughters ages ranging from 19 to 4 months old.
The elder girls are all studying. There is a five-year difference
between the first and second children because I had two
premature births and a miscarriage at five months. After this I
got treated by an Ayurvedic physician from the adjacent village
and my next child was born in 1991. I took birth control
122
injections, but they had adverse effects such as pain, severe

bleeding and periods three times a month. So I stopped taking
the injection and conceived again. After the third child I asked
for a sterilization operation but the doctor refused saying I was
weak and asked that I use the loop. I decided not to use the
loop and took the pill to regulate the next births. With the pill
I had longer and irregular periods. Finally after the sixth child I
underwent the sterilization operation. My husband was against
the operation but he consented because I pressurized him. (JM,
39 Case Study, Batticaloa)
Table 7
Interviewees
who Know About Contraception by
Knowledge
About Contraception
their Age (%)
26.8%
19.0%
0.0%
Age 12-18
Age 19-40
Age 41-60
As the above case study interviews indicate, knowledge about contraception

is not found among most women. There is also a level of mistrust about
the side effects of contraceptives. Only 15 women of the total declared
that they had knowledge of contraception.

Of the forty two women who responded to this question, 40% had had
their first child between the ages 20 and 24. 26.1% were pregnant between
the ages of 15 and 19, indicating that early marriage resulted in almost
immediate pregnancy and supporting the evidence that women either
had no knowledge of contraception or possibly had no access to it. It is
also possible that cultural factors played a role in early marriage and early
childbirth while conflict-related considerations too may have impacted
early marriage and its inevitable consequence of early motherhood.
123
Table 8
40.4%
21.4%
19.0%
9.5%
4.7%
4.7%
0.0%
15-18
16-19
20-24
25-28
29-32
Above 32
NA
Age at Menopause
Most women in the age cohort 40-55 years of whom this question was
asked appear not to have provided an answer, indicating possibly that they
were not aware of menopause. This lack of response is worth further
investigation since in other districts viz. Jaffna - women of the same age
group appeared to have a much greater knowledge of menopause.
Table 9
Age at Menopause
Age at Menopause
36-40
41-45
46-50
50-55
NA
Total
12-18
0
0
0
0
14
14
Age
19-40
0
0
0
0
41
41
41-60
0
2
4
0
15
21
Total
0
2
4
0
70
76
Miscarriage
I am a teacher and am 43 years old. I first conceived soon after
marriage but miscarried three months later. I lost my second
pregnancy too and was blamed for not seeking medical advice.
I consulted a private practitioner who performed a D and C
124
and assured me that there was no problem. He gave me some

tablets. I conceived a third time and was very careful with the
pregnancy and even sought the advice of the village midwife
but miscarried after four months. In desperation my husband
and I decided to consult a doctor at the government hospital.
He performed a D and C again and gave me some tablets.
When I took them my period did not stop. So I stopped taking
the tablets and consulted the doctor again. I was warded in
hospital and given saline, saying I was weak. We then saw an
advertisement and consulted another gynecologist who did a
laproscopy and a dye test. He found a growth of tissue in my
womb and it was removed through an operation. We had to go
for consultations every month and found we couldnt afford
it. We finally adopted a daughter in 2001. (PR, 43 - Case Study,
Batticaloa)
Table 10
Experience of
Miscarriage
Yes
No
NA
Total
12-18
0
1
13
14
Age
19-40
3
13
25
41
41-60
2
3
16
21
Total
5
17
54
76
Women reported having had at least one miscarriage; most miscarriages

were in the first 3 months of pregnancy and to women over 19 years of
age. They had sought medical advice following the miscarriage.
Domestic Violence
I have been subject to domestic violence. He [husband] started
assaulting me when I was 17 years old and my first child was
three months old. He assaulted me till he died because I would
scold him for not going to work regularly, for playing cards
with friends or borrowing money. (Ms.T, 38 - lkCase Study,
Batticaloa)
125
Domestic violence is an issue which many women face, especially upon

marriage. As the table below indicates, the frequency of domestic violence
by spouses appears to be highest during a womans childbearing age.
Table 11
Domestic Violence
Interviewees who have Experienced

34.1%
28.6%
14.3%
Age 12-18
Age 19-40
Age 41-60
Most incidents of domestic violence were reported to have been instigated

by the spouse. The reasons ranged from drunkardness, demand for sexual
services, demand for dowry, infertility, loss of child (including miscarriage),
for asking to visit her parents, or the woman having travelled alone by bus.
There was also some violence reported to have been inflicted by fathers
for reasons such as drunkardness or finances. Mothers are reported to
have used violence for reasons such as having an unauthorized love affair
when the woman was a young girl.
Preganancy during the Period of Conflict

My village was badly affected during the war. We lived in fear of
the army. Sometimes we hid in the forest, at others we moved
into other peoples homes. My second surviving child was
born in the forest even before we could get a midwife. She is
fourteen now but is not very active, possibly because proper care
was not taken during her birth. During the war we were often
displaced and health services too were disrupted. I could not go
to government clinics. Now in peace time I attend government
clinics and my last child was born in a government hospital four
months ago. (JM, 39 - Case Study, Batticaloa)
126
Interviews such as the above indicate that women underwent severe

difficulties during the time of active conflict in the districts included in
this research.
Table 12
Pregnancy During the Conflict Period: Number and Order of Child Births
Age Group
and Number
of
Respondents
Before
Which
Child
1
2
3
4
5
1218
5
4
4
2
1
% of
Sub Total
During
% of
Sub Total
After CFA
% of
Sub Total
Total
Which
Child
1
2
3
4
5
0
Which
Child
1
2
3
4
5
% 1940
1
1
1
% 4160
22
17
11
11
9
5
3
18.6 17
18.6 16
15.2 14
8.4 8
5.0 4
28.8
27.1
23.7
13.5
6.7
16
27.1 39
66.1 59
100.0
11
9
6
4
2
25.5
20.9
13.9
9.3
4.6
9.3 15
6.9 12
4.6 8
2.3 5
2.3 3
34.8
27.9
18.6
11.6
6.9
43
100.0
9
7
4
4
4
28
32.1
25.0
14.2
14.2
14.25
100.0
44.6 130
100.0
8.4
6.7
6.7
3.3
1.6
0 32
3.5
0
0
0
0
3.5
% Total
4
3
2
1
1
11
7
5
2
2
3
19
25.0
17.8
7.1
7.1
10.7
67
51.5 58
1
2
2
2
1
8
3.5
7.1
7.1
7.1
3.5
127
In the Batticaloa District, most childbirths of interviewees had taken place
in hospitals. Only 8% reported home births. Focus group discussions and
case studies revealed that most home births took place when the mother
lived far away from medical centres with little or no transport facilities, or
where the mother could not afford the clothing and other requirements
to enter hospital.
Table 13
Location of Chil birth by Number and Order of Childbirth
Age Group and
Number of
Respondents
Home
Sub Total
Hospital
Sub Total
Other
Sub Total
Total
128
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
12-18
19-40
41-60
Total
%
of
Total
22
17
40
2
1
3
3
2
2
7
5
3
2
0
0
10
1
-
21
14
11
9
3
14
15
13
9
5
36
29
24
18
8
58
56
115
92.1
0
1
0
61
0
63
0
125
100.0
7.8
3.5 Jaffna District
Background
In the absence of comprehensive census data from the North and East
since 1981, the information available at the national level for the Jaffna
District is limited. The Assessment of Needs in the Conflict Affected Areas carried
out in 2003 notes that health infrastructure has been severely affected
in the North and East.58 Historically, the North had exceptionally good
health service delivery structures, which were severely impaired, damaged
or destroyed in the years of conflict. Particularly affected were many
health institutions hospitals, clinics, and water supply and sanitation
systems. Compounding this damage to infrastructure was the widespread
shortage of health personnel. The breakdown of reproductive healthcare
services, which had been among the best in the country, had resulted
in emergency obstetric care and family planning services, drugs and
operational healthcare institutions being unavailable to provide healthcare
to most of the population. Another serious obstacle to the effective
58 UN (2003). Sri Lanka Assessment of Needs in the Conflict Affected Areas: Districts of Jaffna,
Kilinochchi, Mullaitivu, Mannar, Vavuniya, Trincomalee, Batticaloa and Ampara, prepared with
the support of the Asian Development Bank, UN and World Bank, Colombo.
129
delivery of healthcare was the embargoes imposed on many essential

goods, drugs and medical items to the Jaffna peninsula from the late
1980s. The periodic and often long-term restrictions imposed on civilians
by the demarcation of No Go Zones, Security Zones, including the sea
board, and the current High Security Zones also severely handicapped
the delivery of health services. This situation was compounded by
restrictions imposed on movement due to these zones, checkpoints and
various pass systems introduced by the state as well as the military. These
constraints were of course further aggravated by the almost constant
military activity in the district between the LTTE and the state armed
forces, the IPKF and other militant groups from the mid-1980s until the
relative quiet following the ceasefire agreement of February 2002.
The WMC Research Area

The research study for the WMC was carried out in Jaffna by representatives
of the Centre for Womens Development in Jaffna in four areas within
the Jaffna peninsular.
i. Point Pedro: In Point Pedro, the Divisional Secretariat data record a
population of 41,200 comprising 12,195 families, of whom 21,496
were females and 19,604 were males. Approximately 1,426 families were
headed by women. Most of the population was engaged in fishing, with
women also finding manual work for daily wages when possible. It was
also found that there is a pattern of early marriage, between 17-18 years
of age, among women and men. Government hospitals provided the
main source of healthcare.
ii. Navanthurai: The Navanthurai Grama Sevaka Division comes under
the Divisional Secretariat of Jaffna and has a total population of 46,077
persons, of whom 23,860 are females and 22,217 are males. There are
12,981 families living in this area, of which 1,941 are female headed. A
predominantly Tamil area, Navanthurai has seen the entry of a small
number of Muslims; there are currently about 180 Muslim families. The
main provider of healthcare to this population is the Jaffna General
Hospital. It was noted that there is a pattern of Muslim girls dropping
out of school on reaching puberty.
130
iii. Koppai: The Divisional Secretariat records a population of 63,439

comprising 18,170 families, of whom 32,432 are female and 31,007 are
male. Approximately 487 families are headed by women. Many have been
displaced as a result of the ethnic conflict. The main source of income is
from manual work. The district hospital is the main provider of healthcare
to the population.
iv. Savatkkattu: The Savatkattu Grama Sevaka Division comes under the
Chandilippay Divisional Secretariat which has a population of 41,000
persons, of whom 21,496 are female and 19,604 are male. There are
12,195 families living in this area, of whom 2,426 are female headed.
Although this area is not located near the sea, most men are engaged in
fishing and other industries. Most women are engaged in beedi rolling.
The Jaffna General Hospital provides the primary healthcare needs of
this population.
Ethnicity
The Jaffna district sample reflected the broad ethnic distribution of the
population.
Table 1
Ethnicity
Tamil
Muslim
Total
12-18
18
2
20
19.2
Age
19-40
48
6
54
% 41-60
51.9
28
2
30
Total
94
10
28.8 104
90.3
9.6
100.0
Level of Education
The overall educational level of the sample was relatively high with only
two women from the oldest age group recording no formal education.
21% of women from all three age categories were found to have obtained
education between grade 6-8. The highest level of education was found to
131
have been achieved by those in the age group 19-40, with 31.7% obtaining
education levels between grades 6 and 12. The lowest level of education
(Grade 5 or below) was found among those in the age group 41-60.
Table 2
Level of Education

28.8%
21.1%
15.3%
14.4%
5.7%
6.7%
5.7%
1.9%
None
No
12
Education response
Table 3
Divorced, No info,
1.0%
Widowed, 3.8%
3.8%
Unmarried,
26.9%
Married,
64.4%
Of the sample 72% were married or had been married, while 26.9% were
unmarried. This relatively high percentage of unmarried women could well
be directly related to the lack of sufficient men in the younger age group
suitable for marriage. The lower percentage of men in the peninsula has
been attributed to the higher exodus to safer locations; greater numbers
of men joining militant movements and possibly dying in combat; greater
numbers of young men being detained, arrested or disappeared. Another
132
conflict-induced phenomenon is the high premium on men and the larger

dowries demanded by them. Families of women may thus have to spend
a longer period of time collecting the required resources to afford the
almost compulsory demand for dowries. The gendered consequences of
late marriage later pregnancies, potential infertility, high risk births and
older parenthood - are all factors that must be taken into account in the
design of gender-sensitive health policy and the delivery of appropriate
health services to communities affected by protracted conflict.
Age at Puberty
The age at puberty reflected the average figures found in the other five
districts surveyed as part of this research, although Jaffna recorded the
lowest average for the 9-12 age cohort. Of the total number of women
interviewed 72% had reached puberty between the ages 13-15; 8.6 % had
reached puberty between 9-12, and 14.4% between the ages 16-19.
Table 4
Age at Puberty
Age at Puberty
9-12
13-15
16-19
Incomplete info
Total
12-18
1
16
0
3
20
Age
19-40
6
38
8
2
54
Total
41-60
2
21
7
0
30
9
75
15
5
104
%
8.6
72.1
14.4
4.8
100.0

Of the sample, had not been aware of puberty at the age of getting their
first menses; 28.8% had learned about puberty from their friends; and
10.5% from their mothers. More than half the sample had obtained the
knowledge using their own means. This indicates that even today, there
is still not much discussion about physical changes related to womens
reproductive health among family members or within the education
system. Most young people appear to be left to their own devices to
133
seek out relevant information, and this indicates very clearly that accurate,
useful and relevant information must be made accessible to boys and
girls through accessible means, such as the education system, community
youth groups, media and the family.
Table 5
From Whom
Mother
Aunt
Sister
Friends
Own
No response
Total
12-18
3
0
0
7
10
0
20
Age
19-40
4
1
3
17
27
2
54
41-60
4
0
0
6
20
0
30
Total
11
1
3
30
57
2
104
%
10.5
0.9
2.8
28.8
54.8
1.9
100.0
Age at Marriage
This sample indicates that there seems to be a shift to marriage at a
younger age (between the ages 15-18) among the age category of women
who are currently between 19-40, compared with the women who are
currently in the 41-60 age cohort. This appears to be a comparatively
recent phenomenon in Jaffna society.
Overall, 46.1% of women interviewed had been married between the
ages of 15-22, 10.5% between the ages 23-25, and 5.7% above the age of
30. 27.8% of women were unmarried.
134
Table 6
Age at Marriage
29.8%
27.8%
16.3%
10.5%
9.6%
1.9%
15-18
19-22
23-25
26-29
30-33
3.8%
0.0%
Above 33
Unmarried
NA
I was displaced from Atchuveli and later lived in the Vanni.
I left school in 1995 and joined the LTTE. I left the LTTE
after earning my discharge and married in 2000. My parents
accepted me only when I was five months pregnant with my
daughter. I was pregnant again last year but did not know that
I should not do strenuous work during pregnancy. I tried to
shift to a new house during my pregnancy but had to return
because it was already occupied. When I got home I found
a slight discharge. I went by bus to my husbands workplace
and while returning home on the bus found that the blood
flow had increased. While walking home through the shrubs
I fainted and was sent to hospital. From there (Vanni), I was
sent to the Jaffna hospital because the cord had not come out.
At the Jaffna hospital the police questioned me about abortion.
I said I had not had an abortion. The doctor X rayed me and
then discharged me. I found many women who had attempted
abortions at the hospital. (RK, 22 Case Study, Jaffna)
135
In response to the question on how many miscarriages women had

undergone, it was found that ten women in the age category 19-40 had
had one miscarriage compared with nine women in the age category 4160; most of these women had been above 23 at the time of miscarriage.
One woman each from both these age groups had had their first
miscarriage between the ages 16-19. Two women in each of these age
cateogries had suffered 3 miscarriages. Most miscarriages had taken place
in the first 3 months of pregnancy. Eleven (45.8%) women from the two
age categories had sought medical assistance in government or private
hospitals. Three women (12.5%) had sought help from their mothers.
Age at Menopause
Awareness of menopause was found only among the age group 41-60;
most women found out about menopause from their friends, mothers or
grandmothers.
Table 7
Age at Menopause
Age at Menopause
36-40
41-45
46-50
50-55
No response
Total
12-18
0
0
0
0
20
0
Age
19-40
0
0
0
0
54
0
41-60
4
5
7
2
12
30
Total
4
5
7
2
86
104

Most women had learned about contraception from doctors in hospitals
and clinics. There was also mention that some women had learned about
contraception from the organization Population Services Lanka. The most
commonly used form of contraception was reported to be injectibles.
136
Table 8
Knowledge about
Contraception
Yes
No
No response
Total
12-18
1
3
16
20
Age
19-40
42
1
11
54
41-60
23
2
5
30
Total
66
6
32
104
%
63.4
5.7
30.7
100.0

While 52.7% of the total sample had had their first child by the time they
were 28, the fact that 11.5% of women had had their first child between
the ages 16-19 emerges as a key concern in the district.
Table 9
38.4%
27.8%
13.4%
11.5%
5.7%
16-19
20-24
25-28
29-32
2.8%
Above 32
NA
Domestic Violence
He [son-in-law] harassed my daughter very much He gave
my daughter karate kicks and beat her with chains. No one
took action to stop his atrocities. He came in the night and
beat my daughter with a chain. She did not shout because
she did not want me to hear. She went to a neighbolurs and
slept there. In the morning she returned home and slept
with the child. But he returned soon and found her sleeping.
137
He threw the kerosene lamp on her and she started burning.

He locked the door and went out. She pushed the door
open and saved the two children but she was badly burnt
No one tried to save her. I look after her two children. (MN,
52 Case Study, Jaffna)
Table 10
Interviewees
who
have Experienced
Experience
of Domestic
Violence
26.7%
20.4%
10.0%
Age 12-18
Age 19-40
Age 41-60
Most of the violence in the home was reportedly perpetrated by the spouse
for reasons such as not giving him money to buy alcohol, suspicion and
dowry issues. There were also incidents reported of violence perpetrated
by mothers-in-law on account of the woman not getting pregnant.
Mothers and sisters were reported to have used violence in relation to
love affairs or for not agreeing to marry the partner chosen for marriage.
Most women had the first experience spousal violence when they were
in their 20s. In the absence of legislation which criminalizes marital rape,
incidents such as those quoted above continue to take place with no
punishment metered out to the perpetrators of violence.
My eldest daughter fell in love when she was studying and
eloped Her husbands mother came along and took him
away saying the dowry was not sufficient. My daughter went
in search of him and he returned with her. My daughter
conceived and he went away. We were then displaced to
Madduvil I heard he had married another girl at Mirusuvil.
I told the person who had told me that he was married to
my daughter and he came back. In this manner has married
six times. (MN, 52 Case Study, Jaffna)
138
As the above case study illustrates, women face physical and mental abuse
in situations where sociocultural practices such as dowry upon marriage
are deeply entrenched. Such situations are often compounded by families
being displaced due to military engagements by the armed forces and the
resultant breakdown of social norms in society.
Pregnancy during Conflict Period

I am married and have five children. Two of them were
born in hospital and the others at home. During the
IPKF days I could not go to the hospital for the birth of
my first child. My mother looked after the delivery. She
used the instruments available in the house like the blade
and scissors Later in 1993 my mother thought I had
developed labour pains and took me to hospital. Doctors
sent me home saying there were 22 days more. I delivered
the child next morning at home. My experience shows that
it is better to deliver the child at the hospital than at home.
At the hospital, there are facilities to stop excessive bleeding
and to attend to complications I fell very sick after
delivering the baby at home. (PM, 39- Case Study, Jaffna)
The Jaffna study brought out interesting correlations between childbirth
and the different periods of the conflict in the area. 56% of childbirths
had taken place during the period of active conflict.
139
Table 11
Pregnancy During the Conflict Period: By Number and of Order of
Childbirths
Age Group
and
Number of
Respondents
Order of
12-18
childbirth
0
Before
Which
Child
1
2
3
4
5
Sub Total
% of Total
During
Sub total
% of Total
After
Sub Total
Total
140
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
19-40
41-60
Total
36
26
62
3
1
0
0
0
4
20
18
12
6
5
61
23
19
12
6
5
65
35.3
29.2
18.4
9.2
7.6
100.0
33.5
26
24
14
11
6
81
6
6
6
5
5
28
32
30
20
16
11
109
29.3
27.5
18.3
14.6
10.9
100.0
56.1
9
2
2
3
1
2
1
9
2
4
3
2
0
0
17
102
3
92
20
194
45.0
10.0
20.0
15.0
10.0
100.0
100.0
Clearly, the Jaffna data indicates that women currently in the age group
41-60 have had the most number of childbirths, both before and during
the period of active conflict. Whether this situation arose as a result of
the nonavailability or nonaccessibility of reproductive health services in
the area or whether sociocultural factors contributed needs to be further
investigated. It is evident that there has been an increase in the number
of childbirths among women in the age cohort 19-40 in the period after
active military engagement in the area.
While this research found that most women had sought care in hospitals
for the birth of their children, there is also strong evidence to show that
the period of conflict severely disrupted womens access to reproductive
health services provided by the government.
It is evident that the role played by traditional midwives remains a key
factor in ensuring womens access to safe delivery, particularly where
mainstream facilities and care are not accessible.
141
Table 12
Location of Childbirth by Number and Order of Childbirths
Age Group
and
Number of
Respondents
Home
Sub Total
% of Total
Hospital
Sub Total
% of Total
Other
Sub Total
Total
142
Order of
childbirth
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
12-18
19-40
41-60
Total
29
12
41
2
3
1
-
1
2
2
3
3
5
3
0
3
14
7.1
36
24
15
14
7
58
25
22
18
11
9
85
61
46
33
25
16
181
2.8
0
0
0
102
0
93
0
195
21.4
35.7
21.4
0
21.4
100.0
33.7
25.4
18.2
13.8
8.8
100.0
0
100.0
3.6 Ampara District
The Ampara District research study was carried out in 12 areas:

Sinnamuhaththuvaram, Sarakkeni, Akkaraipattu 7, Navatkuda,
Puliyampathai, Oluvil, Palamunai, Panekadu, Periyakulam, Kolavil,
Sinnakulam ande Latchukuda. The research was undertaken by
representatives of the Affected Womens Forum based in Akkaraipattu.
The organization was unable to continue with the second phase of the
research due to the devastation by the 2004 tsunami of large parts of the
districts. Hence, the data below is drawn from the structured questionnaire
administered in the first phase of the research.
143
Ethnicity
The ethnic breakdown of the Ampara sample reflects the broad ethnic
distribution of the district.
Table 1
Ethnicity
Muslim
Sinhala
Tamil
Total
Age
12-18 % 19-40 %
9
26
1
2
12
27
22 (19.6) 55 (49.1)
41-60 % Total
15
50
2
5
18
57
35 (31.2) 112
%
44.6
4.4
50.8
100.0
Level of Education
The highest level of education was found to have been achieved by
those in the age group 19-40. 35.7% of the sample had obtained formal
schooling only up to grade 5 or below
Table 2
Level of Education
35.7%
19.6%
14.2%
15.1%
8.0%
2.6%
None
144
1.7%
1.7%
0.8%
No
12
Education response
Marital Status
The majority (91.9%) of the respondents in the age categories 19-40
and 41-60 were married. 59% of those in the age category 12-18% were
married, while 27.2% were unmarried.
Table 3
Widowed, 0.0%
Divorced, 0.0%
Unmarried,
5.3%
No info, 2.6%
Married, 91.9%
Age at Puberty
Of the total number of women interviewed, 60.7% had reached puberty
between the ages 13-15, 24.1 % between 9-12, and 7.1% between 16-19.
Table 4
Age at Puberty
Age at Puberty
9-12
13-15
16-19
NA
Total
Age
12-18 %
8
12
0
2
22
19-40 %
13
33
6
1
55
41-60 %
6
23
2
4
35
Total
%
27
68
8
7
112
24.1
60.7
7.1
6.2
100.0
145

Of women interviewed, 44.6% had learned about menstruation at
the time of their first menses or from friends. 17% had learned about
puberty from their mothers. This pattern once again reiterates the need
for processes to ensure better reproductive health-related information
among youth.
Table 5
From Whom
Mother
Grandmother
Sister
Friends
Own
NA
Total
12-18
3
2
1
3
10
3
22
Age
19-40
9
0
1
8
17
19
55
41-60
8
1
1
1
11
13
35
Total
20
3
3
12
38
35
112
17.8
2.6
2.6
10.7
33.9
31.2
100.0
Age at Marriage
A high 50.8 % of women interviewed had been married between the
ages of 15-18. When compared with the data in Table 4, this indicates a
close relationship between the age of puberty and marriage. With 25.8 %
married between the ages 19-22, the sample shows that 76.6% of women
had been married by the time they were 22.
146
Table 6
Age at Marriage
50.9%
25.9%
7.1%
15-18
19-22
4.5%
23-25
26-29
1.8%
0.9%
30-33
Above 33
5.4%
3.6%
Unmarried
NA

Of the sample 56.2% reportedly had knowledge about contraception,
while 11.6% had said they did not. 15% of women had learned about
contraception from medical practitioners while 7% had learned from
friends.
Table 7
Knowledge about
Contraception
Yes
No
No response
Total
Age
12-18
19-40
41-60
7
1
14
22
35
9
11
55
21
3
11
35
Total
63
13
36
112
%
56.2
11.6
32.1
100.0
147

Following on from the information on age at puberty and age at marriage,
33% of the sample had had their first child by the time they were 18.
Table 8
33.0%
25.8%
21.4%
8.9%
15-18
19-22
23-25
4.4%
3.5%
2.6%
26-29
30-33
Above 33
NA
Of the interviewees, 25% indicated that they had suffered at least one
miscarriage. Of these, 15.1% had experienced one miscarriage, while
9.8% had experienced between 2 and 3. The majority of those who had
experienced miscarriage had sought medical treatment at hospitals or
clinics in the area.
Table 9
Miscarriage
Yes
No
NA
Total
148
Age Distribution of
Respondents
12-18
19-40
41-60
2
13
13
2
13
2
18
29
20
22
55
35
Total
28
17
67
112
%
25.0
15.1
55.8
100.0
Age at Menopause
Menopause was reported only from women in the age category 41-60.
Of them, only two had been aware of menopause prior to the experience.
Those who had reached menopause had sought advice from a medical
practitioner, 11 (9.8%).
Table 10
Age at Menopause
Age at Menopause
31-35
36-40
41-45
46-50
51-55
NA
Total
12-18
0
0
0
0
0
22
22
Age
19-40
0
0
0
0
0
55
55
41-60
1
3
6
6
2
17
35
Total
1
3
6
6
2
94
112
%
0.8
2.6
5.3
5.3
1.7
83.9
100.0
Domestic Violence
Of the sample surveyed, 49.1% had experienced domestic violence.
Women in the age category 19-40 were among those most likely to
experience domestic violence. It was found that 43.7% reported that it
was their spouse who was the perpetrator.
The most common reasons for spousal violence was his alcoholism,
demand for sexual services, the delay or womans inability to conceive,
his financial problems, his extra marital relationships, and if she was
perceived to not cleaning the house or having his meals ready on time, or
for no known reason.
149
Table 11
Interviewees
Domestic
Violence who have Experienced

58.2%
48.6%
27.3%
Age 12-18
Age 19-40
Age 41-60
Pregnancy during Conflict Years

The survey revealed that of the 227 childbirths recorded for the total
sample, 125 (55%) had been during the time of active conflict in the area,
25.9% before the onset of conflict, and 18.9% after the signing of the
CFA. The most number of children during the period of active conflict
had been born to women in the age category 19-40.
150
Table 12
Pregnancy During the Conflict Period: Number of Childbirths *
Age Group and
Number of
Respondents
Before
Sub Total
% of Total
During
Sub total
% of Total
After
Sub Total
% of Total
Total
12-18
19-40
41-60
Total
35
15
50
44.6
4
4
4
1
1
14
12
12
9
7
5
45
16
16
13
8
6
59
25.9%
27.1
27.1
22.0
13.5
10.1
100.0
34
27
15
5
2
83
8
8
10
8
8
42
42
35
25
13
10
125
55.0
33.6
28.0
20.0
10.4
8.0
100.0
8
7
9
6
5
0
1
14
8
9
6
6
35
132
88
43
18.9
227
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
Which
Child
6
1
1
2
3
4
5
32.5
18.6
20.9
13.9
13.9
100.0
100.0
* Information on 65 childbirths was not available.
151
While most women sought hospital care for the birth of their children,
Ampara data indicates a relatively high incidence of home births compared
with the data from the other five districts. This was most frequent among
the age category 41-60 and could be indicative of poor health delivery
services during the time of conflict.
Table 13
Location of Childbirth by Number and Order of Child Births
Age Group &
Location of
Respondents
Order
of liveBirths
Home
Which
Child
1
2
3
4
5
Sub Total
% of Total
Hospital
Sub Total
% of Total
Other
Sub Total
Total
152
Which
Child
1
2
3
4
5
Which
Child
1
2
3
4
5
Age Group
12-18
19-40
41-60
Total
4
7
5
3
2
21
10
10
10
5
6
41
14
17
15
8
8
62
21.2
22.5
27.4
24.1
12.9
12.9
100.0
6
1
0
45
33
27
10
7
122
22
21
20
20
18
101
73
55
47
30
25
230
78.7
31.7
23.9
20.4
13.0
10.8
100.0
0
7
0
143
0
142
0
292
0
100.0
Annexure 1
Women Questionnaire:
1st Phase
1. INTRODUCTION
Rationale for the Study
Selection of Specific Districts:
Polonnaruwa, Jaffna, Mannar
Moneragala,
Akkaraipattu,
Batticaloa,
Sample Selection: Ages 12-18; ages 19-40; ages 41-60

Number of Interviews/Questionnaires to be completed: 100 per district
A. Personal Information
-- Name
-- Age
-- Ethnicity
-- Religion
-- Level of education
-- Marital status
-- Number of children
-- Age and sex of children
-- Main income earning activity
-- Age at marriage
-- Age at puberty
-- Age at birth of first child
-- Age at birth of last child
-- How long have you been living in this current location?
-- When did you move into this location?
-- Do you have your own family members living in this village/area?
-- Do you have your spouses/fathers/mothers family members living in
your house/this village/area?
-- What is the age of your spouse?
-- Level of education of spouse
-- Ethnicity of spouse
-- Religion of spouse
153
-----
Main income earning activity of spouse

Are you a recipient of Samurdhi?
Are you a recipient of government assistance for rehabilitation? If so,
please specify?
Are you a member of a village/community-based organization (e.g.,
womens organization, savings scheme, etc.)
B. Health Concerns
2. What are your main health problems/concerns?
C. Health Services
-- What are the health services/facilities that you have used ?
-- What are the health services/facilities that are available in your area
(village, district/municipal, cooperative, etc.) ?
-- For what reasons have you used these facilities ?
-- Was the ailment cured as a consequence?
-- What type of services/facilities do you feel are lacking in the area?
D. Reproductive Health
-- What are reproductive health issues as you understand it? (guidance
necessary from Research assistant to bring out issues such as puberty,
menstruation, pregnancy, childbirth, menopause, breast, ovarian
and womb-related health issues, sex, sexually transmitted infections,
contraception).
-- What are your RH problems/concerns?
-- What do you do when you have such a problem (specify depending on
the problem) ?
-- Who do you approach ?
-- What type of treatment have you been asked to take (specify for what
ailment)
-- Are you aware of the type of practices and methods which relate to
reproductive health (e.g., personal cleanliness, regularity in menstruation,
changes in your body, conception, contraceptive methods, etc.)
-- If yes, how did you find out about these?
E. Institutional Healthcare Facilities
-- Have you ever sought medical advice or treatment for reproductive health
problems?
-- If yes, where and when?
-- Preconflict (pre-1983 for North, pre-1990 for East, pre-1989 for the
South) ?
154
--------
During the conflict years ?

Since the ceasefire ?
Who did you speak with regarding the problem (male/female medical
personnel) ?
Were you able to talk freely about your concern?
How do you feel about the response you got from this/these person/s?
Do you feel that there was a difference in talking about such issues with
male/female medical personnel?
If so, specify.
F. Non-Institutional Healthcare services (traditional support/remedies)

-- Who in the community/neighbourhood knows about reproductive health
issues?
-- What are the areas of expertise available among these persons?
-- Have you ever sought advice from these persons?
-- If yes, for what reasons did you do that?
-- If no, for what reasons havent you done that?
-- If yes, when was this ?
-- Preconflict (pre-1983 for North, pre-1990 for East, pre-1989 for the
South) ?
-- During the conflict years ?
-- Since the ceasefire ?
G. Puberty and Related Information
-- How did you learn about puberty? (did someone tell you about it - if so
who, did no one tell you about it, etc.)
-- When did you attain age?
-- Did you tell anyone about it/did someone find out about it? Who was
that person?
-- What were you advised to do?
-- What actually was done and by whom?
-- Were you told about childbirth?
-- Who told you ?
-- How old were you when you learned about it?
H. Pregnancy
-- If you have children, how old were you when you first got pregnant?
-- How old were you when you first delivered a child?
-- Who was your main source of support emotionally/financially - during
this time?,
155
--
--
Where did you birth the child? (in a hospital/ your own home/ another
persons home, etc.)
Who delivered the baby qualified medical doctor, qualified midwife/
traditional midwife/other ?
Was it a normal delivery/caesarian section ?
Were your pregnancies before, during or after the conflict period ?
Which ones were during the conflict years ?
Did you have specific problems during the pregnancies in the conflict
years ?
If yes, what were these ?
--
How did you deal with them ?
------
I. Sub-fertility/Infertility
-- Have you had difficulties in getting pregnant?
-- Why do you think this is the case?
-- What has been/was the response of your spouse/own family/in-laws to
this situation ?
-- Have you sought advice regarding difficulty in getting pregnant?
-- From whom and where?
-- What was the advice you were given?
-- Have you been able to get pregnant subsequently?
H.Contraception
-- Do you have knowledge of contraception ?
-- How did you get this knowledge ?
-- Have you ever used contraception ?
-- What contraception services were/are available to you ?
-- What was the nature of the services available (through clinics, hospital,
regular check-ups, etc.) ?
-- What type of contraception have you/do you use ?
-- Has your spouse ever used contraception ?
-- Do you use traditional methods of contraception ?
-- What choice did you have in deciding on contraception use ?
-- What influenced your choice ?
J. Miscarriage
-- Have you had any miscarriages?
-- If yes, how many?
-- How old were you when this first happened?
156
--------
At which month of pregnancy did you have the miscarriage?

What did you do at that time?
Did you seek medical/family/traditional midwive/s help?
Did/have you tried to get pregnant again?
Were you successful?
If not, have you sought advice regarding this (medical personnel,
traditional midwives, family members specify) ?
What kind of advice/treatment have you been given? (specify)
K. Abortion
-- Have you ever had to get an abortion done?
-- What was the reason for this?
-- How was it done/where/by whom?
-- Did you face any health complications following an abortion?
--
If yes, what did you do ?
L. Menopause
-- At what age did you stop menstruation?
-- Were you aware that this would happen to you?
-- If yes, from whom did you get to know about this?
-- What did you do when this happened?
--
How did your spouse respond to this situation?
M. Violence Against Women

-- Have you ever been subjected violence within your home/community?
-- If yes, by whom (father/brother/mother/sister/spouse/other) ?
-- For what reasons?
-- How old were you when this first happened?
For Married Women Subject to Domestic Violence
-- How long had you been married when you were first subjected to violence
by your spouse?
-- Did you have any children at this time If yes, how many and how old
were they?
-- Has this type of violence been repeated against you?
-- What do you think are the reasons for this? Specify (dowry issues, social
expectations of wifely duties, in-law interventions, inability to conceive,
miscarriage/s, inability to bear male/female children, (perceived) infidelity
his/hers, other)
157
Annexure 2
Women Questionnaire:
2nd Phase
Ages 12-18, 19-40 and 41-60
If the interview is a continuation of a person who was interviewed during the
first phase, please give the corresponding number of the interviewee.
1. Personal Information
-- Name
-- Age
-- Ethnicity
-- Marital Status
-- Level of Education
-- Main source of personal income
-- Main source of household income.
-- Are you a native of this village/area ?
-- Since when have you been living in this area?
2. Education
-- Did you go to school?
-- Where did you go to school?
-- Why did you stop going to school?
-- Have you participated in any skills development/training after leaving
school?
3. Marriage
-- Are you married?
-- Is your husband a native of this village/area?
-- If married, how was the marriage arranged?
-- Was it your choice/parents/relations ?
-- Do you have siblings?
-- What do they do occupation ?
-- Where do they live?
-- Are they married?
-- If yes, how were their marriages arranged?
158
---
Do they have children?

Where did they birth their children?
4. Unmarried
-- Are there plans for you to get married?
-- If so, when how has the marriage partner been found?
-- What do you look for in a husband?
-- Where will you live after marriage?
-- Do you plan to have children immediately after marriage?
-- If yes, why?
-- If no, why not?
-- Are you aware of contraceptive methods?
-- If so, do you plan to use any which methods?
-- If no, do you want to find out about contraceptive methods?
-- Who do you think could tell you about these?
5. If Married
-- How are major decisions made in your household e.g., regarding purchase
of food, rent, medicines, childrens school expenses, festivals? ( Please
find out whether it is the wife or the husband or any other who would
pay for such events)
-- Do you and your husband consult each other on important issues give
examples?
-- Are there issues on which you and your husband have had disagreements?
-- What are these issues (household expenses, personal expenses, visiting
own relatives, use or not use of contraceptives, inability to conceive,
unfaithfulness, etc.)?
-- Do these disagreements result in physical violence against you/husband?
-- How often do such disputes occur?
-- How are such disputes resolved?
6. Reproductive Health
-- What does reproductive health mean to you? (encourage an extended
discussion to elicit how reproductive health is understood by her)
-- Are you aware of who in the village is the most knowledgeable about
reproductive health issues?
-- Do you know whether there is a clinic or hospital nearby where you can go
for medical help if you have some reproductive health related problem?
-- If you have gone to such a place did you go with someone else? If so,
with whom?
159
7. For Older Women

-- Do you get your periods regularly?
-- If not, have you talked with anyone about irregular periods or if your
period has stopped?
-- Have you sought medical advice or treatment in such an event? If so,
from whom, and why did you decide to speak with that person?
-- Do you feel that you have been able to understand why your periods have
changed?
-- Do you feel that your problem with your periods has been resolved after
these consultations?
160

Reproductive Rights: An Unacknowledged Casualty of Conflict in Sri Lanka

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Reproductive Rights :

The Women and Media Collective

Reproductive Rights: An Unacknowledged Casualty of Conflict

Women and Media Collective

56/1, Sarasavi Lane, Castle Street, Colombo 8, Sri Lanka.

2.3 Reproductive Health and Gender-based Violence............................ 43

1. Selected Health Status Indicators for the Conflict -

he international conferences of the 90s created unprecedented

Contentious and sensitive issues need to be constantly supported and

the conferences also gave an indication of the kind of challenges one

conflict underpinned by deep ethnic divides, marginalization and rampant

so on. And each time newer categories of vulnerable women emerge as a

In situations of armed conflict assertion of ethnicity and identities is often

ex Programme Officer, Ford Foundation

his study analyses the experiences of women living in areas of Sri

A human rights framework provides a foundation to address issues of

both in terms of freedoms and entitlements for women. A rights framework

1.1 Exploring a Reproductive Rights Framework

must necessarily engage with issues of gender inequality whereby women

director of the Population Division of the Ministry of Health and

1.2 Recognition of the Impact of Conflict on Health Services

subcommittee on immediate humanitarian and relief needs (SIHRN) and

many obstacles. Where hospitals had been damaged, obstetric care

1.3 National Health Policy and Programmes

Divisional Director and oversees health issues and institutions at the

PSL is Sri Lankas main provider of contraceptive services. It has been

Furthermore, gender-based and sexual violence remains an endemic

1.4 Reproductive Health in Conflict and Displacement Settings

to promote healthy living and behaviour patterns is very poor. In addition,

Underweight 0-5 years

North and East

Source: SIHRN 2003. Needs Assessment Survey.

The indicators described in Table 1 suggest the serious impact of conflict

(2005), that maternal mortality rates in conflict-affected districts such as

24 Department of Census and Statistics, op. cit.

2. The Women and Media Collective

2.1 Scope and Methodology

districts studied was an important factor in conceptualizing the research

held in Anuradhapura with representatives from the Puttalam and Mannar

2.1.1 Ethnic Distribution of Respondents

2.1.2 Age Distribution of Interviewees

2.1.3 Level of Education of Interviewees

In terms of access to education, 30% of women in the different districts

2.1.4 Marital Status of Women

It is interesting to note that while the number of divorcees overall was

2.2 Lifecycle Approach to Reproductive Health and Rights

2.2.1 Age at Puberty

Age at puberty among girls living in conflict-affected districts reflected

2.2.2 Age at Marriage

100.0 100.0 100.0 100.0 100.0 100.0 100.0

2.2.3 Age at First Live Birth

As the above table indicates, there seems to be a further correlation

of access to contraception, and sociocultural factors preventing women

2.2.4 Knowledge of Contraception

The Batticaloa district findings present the exception on this issue

2.2.5 Experience of Miscarriage

2.2.6 Age at First Miscarriage

* Information on age at first miscarriage of four women was not available.

2.2.7 Age at Menopause

groups and community-based organizations working among IDPs have

2.2.8 Location of Child birth

29. Needs assessment survey 2003,op. cit.

2.2.9 Traditional Midwives