Addressing Domestic Violence in Antenatal Care Environments2

Domestic violence (DV) in pregnancy can cause serious adverse maternal and neonatal health effects. Antenatal care (ANC) presents opportunities to reduce these health consequences. Most women use ANC services in their lifetimes, including in Nepal, where this project is based. Evidence of the effectiveness of interventions to address DV in ANC is largely from studies conducted in high-income countries. 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 in low-income country contexts. How can knowledge from high-income countries be contextually adapted to be relevant and useful in other settings? How can effective low-cost interventions be set in place? How will such interventions reach women in the most remote areas where all types of health services are limited? In contexts where few women living with domestic violence are able to leave the relationship, how can health providers assist in mitigating potential harms to women's health during pregnancy? From 2013-2018, the Addressing Domestic Violence in Antenatal Care Environments (ADVANCE) collaboration conducted studies which addressed questions in two countries - Nepal and Sri Lanka. The Research Council of Norway has now awarded funding for a continuation of the project in Nepal, ADVANCE 2, 2020-2025. Partner institutions are the Norwegian University of Science and Technology, Kathmandu Medical College and Teaching Hospital (Nepal), Dhulikhel Hospital-Kathmandu University School of Medical Sciences (Nepal), OsloMet and University of South-Eastern Norway (Norway), Linnæus University (Sweden), and Johns Hopkins University School of Nursing (USA). By the end of the project, we aim to have developed an evidence-based program for assessment and interventions to victims of domestic violence that can be adopted into antenatal care in Nepal.

The proposal builds on the accomplishments of a prior study which established an international collaboration of researchers and health providers addressing the field of domestic violence (DV). The Sustainable Development Goals reinforced the importance of reducing violence against women for optimal health and as a prerequisite for the achievement of the global targets. Our focus is on reducing DV in pregnancy, an important cause of poor pregnancy outcomes. DV is highest in low-income countries, yet the scientific evidence for interventions in antenatal care (ANC) is most lacking in these contexts. Our study will remedy this gap by employing interdisciplinary research methods in four work packages (WPs) to address DV in ANC settings in Nepal. In WP1, we will develop and formally validate a DV screening tool for clinical use, with input from expert and user judges. We will also assess our developed electronic method of screening. The instruments will then be used in WP2, a randomized controlled trial (RCT) of women identified as experiencing DV after screening a group of 1600 non-selected pregnant women attending ANC in two hospital settings. The intervention group will receive flipchart-based safety-promoting education. The control group will receive standard care which also ensures safety and referrals. All women will be assessed six months after birth. The primary outcome is improved mental health; secondary outcomes include increased use of safety measures, less fear of a person in the family, and improved perinatal outcomes. We will evaluate contextual factors influencing the implementation and effectiveness of the intervention in WP3, using qualitative interviews. In WP4, we will explore the feasibility of implementing measures to address DV in rural areas of Nepal in focus group discussions with women and health providers. Partners in Nepal are in key positions to facilitate uptake of the findings and inform clinical guidelines and policy on a national level.