By: Jennifer Infanti, researcher at Department of Public Health and Nursing
In pregnancy, the experience of domestic violence can have serious adverse maternal and neonatal health effects, and epigenetic studies indicate long-lasting consequences on children as they grow into adulthood. Antenatal care is a window of opportunity to reduce these harmful health consequences as most women use these health services in their lifetimes.
The vast majority of evidence on the effectiveness of interventions to address domestic violence in antenatal care contexts is from studies conducted in high-income country contexts. The result is that scholarship, research methods, clinical practices and guidelines often fail to adequately reflect the realities of life for millions of women around the world and the health systems these women can access. Considerable knowledge gaps exist in terms of health sector approaches to effectively address domestic violence in low-income country settings.
The ADVANCE-project (Addressing Domestic Violence in Antenatal Care Environments) has been granted funding from The Research Council of Norway to further its aim of gaining knowledge about domestic violence during pregnancy in a low-income country context and integrating the actions and evidence from the project into Nepal’s health systems.
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? These are questions we will answer in the continuation of the project starting in mid-2020.
The ADVANCE-study team has completed a pioneering assessment of the burden of domestic violence in pregnancy in Nepal. We found a substantial proportion (21%) of pregnant women reported the experience of domestic violence, as published in the Scandinavian Journal of Public Health in August 2017. Young age and low socio-economic status were particular risk factors for experiencing domestic violence. Women who reported having their own income and the autonomy to use it were at significantly lower risk of domestic violence compared to women with no income. The study also found that few women had ever disclosed their experience of domestic violence to a health care provider or been asked about domestic violence by a health provider. This underlines the importance of integrating culturally-sensitive and systematic assessment of domestic violence into antenatal care in the future in Nepal.
With ADVANCE 2, our team is planning to improve the assessment instrument we developed for the prevalence study, and formally validate it. The assessment instrument is an adapted version of the Abuse Assessment Screen (AAS), a widely-used five-item instrument originally developed in the USA to detect violence against pregnant women. We have translated the instrument to Nepali language and developed an electronic method of data capture for it called a Colour-Coded Audio Computer-Assisted Self-Interview (C-ACASI). Women wear headphones connected to a tablet computer, listen to the questions read to them by a recorded voice through the headphones, and respond to the answers by pressing colour-coded options (for example, in our study, red = yes and green = no). This technology allows women to answer sensitive questions about domestic violence in privacy in otherwise busy antenatal care settings. Importantly, it also allows for the inclusion of participants with limited or no literacy. In Nepal, the female literacy rate is approximately 67%.
We have also carried out an extensive qualitative study with 41 men and 76 women in 12 focus group discussions in community settings to explore perceptions of domestic violence in pregnancy. This was published in Global Health Action in 2016. In this work, we learned that other events than those covered in the AAS could be classified as domestic violence in Nepal and have the potential for harmful effects on a woman’s pregnancy. The community members identified culturally-specific forms of DV such as mothers-in-law restricting or denying food to pregnant women; being forced to perform long days of heavy manual labour into late pregnancy; bullying, belittling, threats and psychological stress related to dowries; and psychological stress related to cultural preference, familial pressure and taunting to give birth to a son.
ADVANCE 2 builds on this prior knowledge. In the new study, we will modify the AAS to ensure it captures culturally-relevant examples of domestic violence, particularly types of emotional abuse. Our aim is therefore to create the Nepalese Abuse Assessment Screen (N-AAS), which will then be formally validated in our two partner hospitals (Dhulikhel Hospital and Kathmandu Medical College).
Of course, it is critical not only to identify pregnant women living with domestic violence but also to provide them with assistance. In our prior work, we assessed the impact of a safety-promoting intervention delivered on an antenatal care ward at Kathmandu Medical College, in a cohort study. Pregnant women between 12-28 weeks gestation were recruited to the study at their regular antenatal care appointments at the hospital. They were educated about safety measures by a nurse or researcher using a pictorial flipchart that we developed in a teaching session lasting for a maximum of 30 minutes. The flipchart was based on a standardised safety behaviour checklist, originally created in a high-income country setting. We adapted the checklist to ensure the relevance of the safety behaviours for women in Nepal. The figure below is an example of the safety behaviours.
The findings of our study were promising. We observed that the range of safety measures used by women increased from baseline to follow-up. However, the main weakness was the follow-up cohort study design as we were unable to compare the use of safety measures with other types of intervention. Therefore, in ADVANCE 2, we plan to test the intervention in a randomised controlled trial compared to standard care in both of our partner hospitals. This will expand the evidence-base on health sector interventions to address domestic violence in low-income country settings. The long-term goal is to integrate safety planning into standard antenatal care in Nepal.