Evaluating interventions in antenatal care to identify and assist victims of gender based violence in Nepal and Sri Lanka

Domestic violence (DV) in pregnancy can cause serious adverse maternal and neonatal health effects, and antenatal care (ANC) presents opportunities to reduce these health consequences. Most women use ANC services in their lifetimes. However, evidence of the effectiveness of interventions to address DV in ANC is largely from studies conducted in high-income countries. Thus, there are significant knowledge gaps when developing clinical practices and guidelines to support the work of ANC providers to identify and assist pregnant women experiencing DV. From 2013-2018, the Addressing Domestic Violence in Antenatal Care Environments (ADVANCE) collaboration has filled some of these gaps in Nepal and Sri Lanka. The ADVANCE partner institutions include the Norwegian University of Science and Technology (Norway), Kathmandu Medical College and Teaching Hospital (Nepal), Dhulikhel Hospital-Kathmandu University School of Medical Sciences (Nepal), University of Sri Jayewardenepura (Sri Lanka), Oslo Metropolitan University (Norway), Linnæus University (Sweden), and Johns Hopkins University School of Nursing (USA). In Nepal, we developed a method to interview women about DV with a Colour-Coded Computer-Assisted Self-Interview (C-ACASI) to ensure confidentiality in busy ANC settings. We found a substantial proportion (21%) of pregnant women reported the experience of DV. Young age and low socioeconomic status were particular risk factors. Few women had ever disclosed their experience of DV to a health care provider or been asked about DV by a health provider. This underlines the importance of integrating respectful and systematic assessment of DV into ANC in the future in Nepal. We also conducted a qualitative study in Nepal with men and women in rural community settings to explore perceptions of DV in pregnancy (published article). We learned that other events than those covered in standardised DV assessment instruments may be considered as DV and have harmful effects on a woman's pregnancy. The community identified culturally-specific forms of emotional abuse, such as mothers-in-law restricting or denying food to pregnant women and bullying, belittling, threats and psychological stress related to dowries. In the future, it is important to include these culturally-specific forms of DV in assessment instruments. It is critical also to provide assistance to pregnant women living with DV. Therefore, in Nepal, we assessed the impact of a safety-promoting intervention delivered on an ANC ward in a cohort study. Pregnant women were educated about safety measures at their regular ANC appointments, using a pictorial flipchart that was locally developed to ensure cultural sensitivity and relevance. The findings were promising, with the range of safety measures used by women increasing from baseline to follow-up time points. The long-term goal is to integrate safety planning into standard ANC in Nepal. Finally, a policy analysis was completed in Nepal (published article), which identified current opportunities in the health sector to address various forms of gender-based violence, supporting the rationale for our study. Our aims for ADVANCE in Sri Lanka, where DV has been recognised as a public health issue for longer than in Nepal, were to: (1) assess the impact of existing health sector interventions to address DV, including the attitudes of health care professionals towards the interventions; and (2) compare the practices of ANC providers in two communities which differ in terms of DV interventions. The chosen districts were the rural tea estates of Badulla and the urban capital of Colombo. We found that DV is prevalent in women's lives in both districts, but highest in the tea plantation sector (published article). Of the 2088 women who participated, 38.8% reported they had ever been asked about DV by health providers. The women who were least likely to have been asked were living in the tea plantation sector and had the lowest formal education. Amongst the 38.6% of women who reported experiencing any kind of abuse in their lifetimes, only 8.7% had disclosed this information to a health care worker. These statistics exist in a context where many health providers have received training on DV and where policy guidelines encourage health providers to systematically ask women about DV in clinical consultations. Thus, ADVANCE carried out two qualitative studies in Sri Lanka to explore the barriers and constraints health providers face in their efforts to respond to DV and how women's trust in their care providers affects their willingness to disclose DV. The findings from these sub-studies (published articles) have the potential to guide further improvements to health care guidelines and training. The health policy analysis we completed in Sri Lanka (also published) indicates that a new national plan to address violence against women has given the health sector a clearer role and mandate to continue these efforts.

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Gender-based violence (GBV) covers a range of events that have the potential to physically and mentally harm women and children. This project focuses on violence that occurs within families. The project was initiated by partners in Nepal and Sri Lanka and builds upon existing international multidisciplinary research collaboration. In Nepal, GBV has recently become a public issue, whereas in Sri Lanka the Ministry of Health runs a training programme for health care workers in antenatal care and has set up hospital-based services for victims. We have adapted the framework for ?steps to conduct evaluation of complex interventions to improve health? in order to develop our project using both qualitative and quantitative methods. Policy analysis will be conduc ted in both Nepal and Sri Lanka in order to learn from the process in Sri Lanka to identify challenges as to national scale-up in Nepal. Our aims for Nepal are to: (1) define the components of intervention and assessment of outcome (2) conduct training of health personnel, informed by (1), and assess the feasibility (3) conduct an impact study by following up victims cared for by trained health personnel and assess the victims safety behaviour postpartum. Our aims for Sri Lanka, where interventions have been developed and piloted in some regions, are to (1) assess the impacts of the intervention and also the attitudes of health care professionals towards the intervention, (2) compare detection rates and referrals among pregnant women in a community with an ongoing intervention and compared the findings to what is the case in a control community without such an intervention. It is anticipated that the proposed combined research activities in Nepal and Sri Lanka will have synergistic effects on the initiat ives in both countries, which in turn will have an impact on the scale-up.