A collaborative research project (2013-2018)
Gender-based violence (GBV) is prevalent around the world and covers a range of events which pose significant risks for physical, sexual and psychological health, in addition to social and economic well-being.
The Addressing Domestic Violence in Antenatal Care Environments (ADVANCE) study focuses on violence experienced by women in their families – domestic violence. The overall project objective is to improve antenatal care services for women living with domestic violence in Nepal and Sri Lanka in order to reduce maternal and infant morbidity and mortality.
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
Benefits of the results for society
High-level government officials were engaged in Nepal and Sri Lanka from the project start to end. Stakeholders representing different levels of government, NGOs, health providers, educators, and media have articulated commitments to plans of action to address domestic violence through the health sectors in Nepal and Sri Lanka. The project’s findings have given momentum and legitimacy to domestic violence prevention and intervention efforts in the health sector.
Future plans for the project
Two spin-off research projects from the ADVANCE study are already underway:
- A randomized controlled trial among pregnant women from different ethnic backgrounds in Norway aimed at improving use of safety measures. This project was developed by one of the ADVANCE study members and PhD supervisors, Mirjam Lukasse (Oslo Metropolitan University), based on experiences she gained with our cohort intervention study in Nepal.
- A pilot study in Sri Lanka of an education intervention using participatory theatre to address the mistreatment of women by health providers during antenatal care and childbirth. This is a mixed methods evaluation of the feasibility and appropriateness of the intervention led by ADVANCE study member and PhD supervisor, Katarina Swahnberg (Linnaeus University, Sweden).
Additionally, the team has written a proposal for ADVANCE 2 in Nepal, focused on further developments based on the achievements of the original study. The key objectives of ADVANCE 2 are to:
- improve the safety-promoting intervention and compare with other types of intervention in a randomised controlled trial (RCT)
- formally validate the assessment instrument to identify women living with domestic violence in antenatal care settings, and also explore ease of use and impact of electronic delivery of the assessment
- undertake a needs and feasibility assessment of interventions for women living with domestic violence in remote areas of Nepal.
Partners and collaboration
ADVANCE was initiated by partners in Nepal and Sri Lanka, and is now a research collaboration of four scientific institutions. The coordinating institution is the Norwegian University of Science and Technology (NTNU) in Trondheim, Norway. The collaborating institution in Nepal is Kathmandu University (KU), including two affiliate institutes: Dhulikhel Hospital-Kathmandu University School of Medical Sciences (DH-KUSMS) & Kathmandu Medical College and Teaching Hospital (KMC). The collaborating institution in Sri Lanka is the University of Sri Jayewardenepura in Colombo. The research team also includes advisors and researcher associates from the Johns Hopkins School of Nursing in Baltimore (USA), the London School of Hygiene and Tropical Medicine (LSHTM), and Linnaeus University in Kalmar (Sweden).
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).
- Addressing domestic violence through antenatal care in Sri Lanka’s plantation estates: Contributions of public health midwives. J.J. Infanti, R. Lund, M.M. Muzrif, B. Schei, and K. Wijewardena. Social Science & Medicine 145 (2015): 35-43 https://www.sciencedirect.com/science/article/pii/S0277953615301398?via%3Dihub
- Agenda setting and framing of gender-based violence in Nepal: How it became a health issue. M. Colombini, S.H. Mayhew, B. Hawkins, M. Bista, S.K. Joshi, B. Schei, and C. Watts. Health Policy & Planning 31, no. 4 (2016): 493-503 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5007602/
- Community perceptions on domestic violence against pregnant women in Nepal: A qualitative study. K.D. Pun, J.J. Infanti, R. Koju, B. Schei, and E. Darj. Global Health Action 9 (2016): 31964 https://www.tandfonline.com/doi/full/10.3402/gha.v9.31964
- ‘They just walk away’ – Women’s perception of being silenced by antenatal health workers: A qualitative study on women survivors of domestic violence in Nepal. P. Rishal, S.K. Joshi, M. Lukasse, B. Schei, and K. Swahnberg. Global Health Action 9 (2016): 1838 https://www.tandfonline.com/doi/full/10.3402/gha.v9.31838
- Prevalence and associated factors of domestic violence among pregnant women attending routine antenatal care in Nepal. P. Rishal, K.D. Pun, E. Darj, S.K. Joshi, J.H. Bjørngaard, K. Swahnberg, B. Schei, and M. Lukasse. Scandinavian Journal of Public Health (2017): 1-9 https://journals.sagepub.com/doi/full/10.1177/1403494817723195?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed
- Factors shaping political priorities for violence against women – Mitigation policies in Sri Lanka. M. Colombini, S.H. Mayhew, R. Lund, N. Singh, K. Swahnberg, J. Infanti, B. Schei, and K. Wijewardene. BMC International Health and Human Rights 18, no. 1 (2018): 22 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5970471/
- Domestic violence: A cross-sectional study among pregnant women in different regions of Sri Lanka. M.M. Muzrif, D. Perera, K. Wijewardena, B. Schei, and K. Swahnberg. BMJ Open 8, no. 2 (2018): e017745 https://bmjopen.bmj.com/content/8/2/e017745
- ‘When helpers hurt’: Women’s and midwives’ stories of obstetric violence in state health institutions, Colombo District, Sri Lanka. D. Perera, R. Lund, K. Swahnberg, B. Schei, and J.J. Infanti. BMC Pregnancy & Childbirth 18, no. 1 (2018): 211 https://www.ncbi.nlm.nih.gov/pubmed/29879946
- Exposure to domestic violence influences pregnant women’s preparedness for childbirth in Nepal: A cross-sectional study. K.D. Pun, P. Rishal, J.J. Infanti, J.H. Bjørngaard, R. Koju, B. Schei, and E. Darj. PLoS One 13, no. 7 (2018): e0200234 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0200234
- Domestic violence and perinatal outcomes–a prospective cohort study from Nepal. K.D. Pun, P. Rishal, E. Darj, J.J. Infanti, S. Shrestha, M. Lukasse, and B. Schei. BMC Public Health 19 (2019): 671 https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-6967-y
Postgraduate degrees awarded during the project
- Doctor of Philosophy (PhD) awarded to Poonam Rishal by the Norwegian University of Science and Technology. Title: Domestic Violence and Pregnancy in Nepal: Developing and Evaluating Interventions in Antenatal Care to Improve the Safety of Women. Supervised by Mirjam Lukasse (lead), Sunil Kumar Joshi, Katarina Swahnberg, Johan Håkon Bjørngaard and Berit Schei. Research carried out in collaboration with Kathmandu Medical College and Teaching Hospital. Successfully defended on 26 April 2018. Abstract online here: https://ntnuopen.ntnu.no/ntnu-xmlui/handle/11250/2564758
- Doctor of Philosophy (PhD) awarded to Kunta Devi Pun by the Norwegian University of Science and Technology. Title: Domestic Violence and Pregnancy in Nepal – Perceptions, Prevalence, Birth Preparedness and Perinatal Outcomes. Supervised by Elisabeth Darj (lead), Jennifer Infanti and Rajendra Koju. Research carried out in collaboration with Dhulikhel Hospital-Kathmandu University School of Medical Sciences. Successfully defended on 24 April 2018. Abstract online here: https://ntnuopen.ntnu.no/ntnu-xmlui/handle/11250/2564639
- Doctor of Medicine (MD)–Community Medicine awarded to Dinusha Chamanie Perera by the Postgraduate Institute of Medicine, University of Colombo, Sri Lanka. Title: Prevalence and Correlates of Adverse Experiences in Health Care among Antenatal Women in the District of Colombo, Sri Lanka. Supervised by Kumudu Wijewardena (lead), Berit Schei and Katarina Swahnberg. Research carried out while enrolled at the University of Sri Jayewardenapura. Successfully defended in 2015
- Doctor of Medicine (MD)–Community Medicine awarded to Mohamed Munas Mohamed Muzrif by the Postgraduate Institute of Medicine, University of Colombo, Sri Lanka. Title: Prevalence and Correlates of Gender-Based Violence in Pregnant Women and Outcome of Pregnancy in Abused Women in Estate Sectors of Badulla District. Supervised by Kumudu Wijewardena (lead) and Ragnhild Lund. Research carried out while enrolled at the University of Sri Jayewardenapura. Successfully defended in September 2015