First phase: ADVANCE 2013-2018

A collaborative research project

First phase: ADVANCE 2013-2018


The project's objectives and background

Our senior partners in Nepal and Sri Lanka initiated the ADVANCE project in 2012. They approached Berit Schei, professor of women’s health at the Norwegian University of Science and Technology (NTNU), for support to design a study with the potential to improve the health systems in Nepal and Sri Lanka for women living with domestic violence. The burden of gender-based violence, including domestic violence, is high in both Nepal and Sri Lanka. The group decided to focus the study on improvements to antenatal care services because most women around the world, including in Nepal and Sri Lanka, use these health services in their lives.

The experience of domestic violence in pregnancy can have serious and long-lasting adverse maternal and neonatal health consequences, and antenatal care presents opportunities for health providers to identify and assist pregnant women experiencing domestic violence. To date, however, evidence on the effectiveness of interventions to address domestic violence in antenatal care is largely from studies conducted in high-income countries. Thus, there are significant knowledge gaps when developing clinical practices and guidelines in low-income countries to support the work of antenatal care providers to identify and assist pregnant women experiencing domestic violence.

The ADVANCE study aimed to fill some of these gaps.

The study’s overall objective was to increase knowledge on effective health sector interventions for women experiencing domestic violence in Nepal and Sri Lanka, ultimately to reduce morbidity and mortality. Secondarily, the project’s objectives were to:

  • compare policy frameworks in Nepal and Sri Lanka
  • develop contextually relevant instruments to assess domestic violence in antenatal care 
  • assess the impact of training on domestic violence on the attitudes of antenatal care providers
  • assess the feasibility and impact of interventions in antenatal care to identify women living with domestic violence and improve their safety during pregnancy

What we achieved

What we achieved

Team picture

At the project’s end, we have made progress in Nepal and Sri Lanka in terms of positive changes in health care for women living with domestic violence.

We have increased knowledge about the significance and scope of the phenomenon of domestic violence and the women who are at highest risk in pregnancy.

We have clear ideas now of how to integrate culturally sensitive systematic assessment of domestic violence and safety planning into standard antenatal care practice. 

The study has raised the profile of the issue of domestic violence and legitimised the roles of the health sectors in Nepal and Sri Lanka in efforts to reduce domestic violence and mitigate its harms.

We have increased the capacity of health providers to understand the experience of domestic violence through training, and have gained new knowledge to further develop and improve the training of health providers in the future.

Highlights of the study’s achievements include:

  • Development of an instrument to assess the burden of domestic violence in pregnancy in Nepal and a pioneering prevalence study with over 2000 women. Additionally, two qualitative studies in Nepal provided information on risk and protective factors, social norms and other drivers of domestic violence, as well as women’s expectations from antenatal care providers.
  • The assessment of victims’ expectations from antenatal care led partners in Nepal to deliver 3-days of training for health providers on the role of the health sector in addressing gender-based violence.
  • The qualitative studies in Nepal and Sri Lanka provided input for further revisions to the content and pedagogical techniques for training nurses and midwives.
  • More than 1000 pregnant women in Nepal received education on safety-promoting measures at their regular antenatal care appointments; 62 of them were followed-up after childbirth to assess the effectiveness of the safety education.
  • We consulted health providers in Sri Lanka about the training they have received to improve their capacity to assist pregnant women living with domestic violence. Their assets, constraints, strategies were evaluated and recommendations were made to government stakeholders to improve their training and work conditions.
  • The study also led to innovations in research technology and methods development, advancing the status of knowledge of interventions in antenatal care to identify and assist women experiencing domestic violence in low-income country (LIC) contexts. We have also developed spin-off research projects.



PhD Study: Domestic Violence and Pregnancy in Nepal: Developing and Evaluating Interventions in Antenatal Care to Improve the Safety of Women

  • PhD candidate: Poonam Rishal
  • Supervisory team: Mirjam Lukasse (lead), Sunil Kumar Joshi, Katarina Swahnberg, Johan Håkon Bjørngaard and Berit Schei
  • Quantitative studies: (i) to assess the prevalence of and factors associated with domestic violence among women attending routine antenatal care at two hospitals in Nepal; and (ii) to implement and assess an intervention to increase the use of safety behaviours by pregnant women experiencing domestic violence.  Study instruments: questionnaire including Abuse Assessment Screen (AAS) in addition to other scales, administered via a colour-coded audio computer-assisted self-interview (C-ACASI) technique; MacFarlane & Parker's Safety Behaviour Checklist (1994).
  • Qualitative study to explore how women who had prior experinece of domestic violence evaluated the antenatal care they received.
  • Abstract of PhD thesis available here. Published journal articles: prevalence study, qualitative study, safety intervention study currently submitted for review.


PhD study: Domestic Violence and Pregnancy in Nepal – Perceptions, Prevalence, Birth Preparedness and Perinatal Outcomes

  • PhD candidate: Kunta Devi Pun
  • Supervisory team: Elisabeth Darj (lead), Jennifer Infanti, Rajendra Koju
  • Quantitative studies: (i) to assess the prevalence and factors associated with domestic violence among women attending routine antenatal care at two hospitals in Nepal, and (ii) to explore associations between the experience of domestic violence, emotional well-being and birth preparedness and complication readiness. Study instruments: AAS (via C-ACASI), HSCL-5, JHPIEGO BP-CR.
  • Qualitative study to explore community perceptions on domestic violence and violence against women during pregnancy, including men's (partner's) views.
  • Abstract of PhD thesis available here. Published journal articles: prevalence study, qualitative study, birth preparedness study.

Policy study: Agenda setting and framing of gender-based violence in Nepal: How it became a health issue

  • Research lead: Manuela Colombini
  • Co-researchers/advisors: Susannah Mayhew, Ben Hawkins, Meera Bista (Research Assistant), Sunil Kumar Joshi, Berit Schie, and Charlotte Watts
  • The study draws on the concepts of agenda setting and framing to analyze the historical processes by which gender-based violence became legitimized as a health policy issue in Nepal, exploring the factors that facilitated and constrained the opening and closing of windows of opportunity. The results are based on a document analysis of the policy and regulatory framework around gender-based analysis in Nepal. A content analysis was undertaken.
  • Published journal article available here.

Sri Lanka

Sri Lanka

MD study: Prevalence and Correlates of Gender-Based Violence in Pregnant Women and Outcome of Pregnancy in Abused Women in Estate Sectors of Badulla District

  • MD candidate: Mohamed Munas Mohamed Muzrif
  • Supervisory team: Kumudu Wijewardene (lead) and Ragnhild Lund
  • Quantitative studies on prevalence and consequences of violence against pregnant women, including sub-analyses on factors promoting risk and resilience, and pregnancy outcomes for abused vs. non-abused women. Study instruments: AAS + WHO.
  • Qualitative study on the services available for abused women, victim’s views and caregiver’s views on abuse in Sri Lanka's tea estate sectors.
  • Study setting: estate sectors of Badulla district.
  • Published journal articles: cross-sectional study on domestic violence here, qualitative study on the roles of public health midwives in addressing domestic violence here.


– MD study: Prevalence and Correlates of Adverse Experiences in Health Care among Antenatal Women in the District of Colombo, Sri Lanka

  • MD candidate: Dinusha Chamanie Perera
  • Supervisory team: Kumudu Wijewardene (lead), Berit Schei and Katarina Swahnberg
  • Quantitative study on prevalence and consequences of violence against pregnant women, including abuse perpetrated by health care workers in antenatal care settings. Study instruments: AAS + NorAQ questions on abuse in health care system.
  • Qualitative study on women's adverse experiences in antenatal care and childbirth settings.
  • Study setting: Colombo district central and field maternal and child health services facilities.
  • Published journal articles: cross-sectional study on domestic violence here, qualitative study on obstetric violence here


– Policy study: Factors shaping political priorities for violence against women – Mitigation policies in Sri Lanka

  • Research lead: Manuela Colombini
  • Co-authors: Susannah Mayhew, Ragnhild Lund, Navpreet Singh, Katarina Swahnberg, Jennifer J. Infanti, Berit Schei, and Kumudu Wijewardene
  • Violence against women (VAW) is a recognized global public health issue but VAW is often unrecognized in legal and health policy documents. This study uses Sri Lanka as a case to explore the factors influencing the national policy response to VAW, particularly by the health sector. A document-based health policy analysis was conducted to examine policy responses to VAW in Sri Lanka using the Shiffman and Smith (2007) policy analysis framework.
  • Published journal article available here.


logos of parnters



ADVANCE was funded by the Research Council of Norway from 2013-2018, with additional financial support from The Liaison Committee for Education, Research and Innovation in Central Norway (Samarbeidsorganet). 

logo: The Research Council of Norway

logo Helse-Midt Norge

21 Jun 2022