Addressing domestic violence through antenatal care in Sri Lanka's plantation estates: Contributions of public health midwives

Abstract

Domestic violence in pregnancy is a significant health concern for women around the world. Globally, much has been written about how the health sector can respond effectively and comprehensively to domestic violence during pregnancy via antenatal services. The evidence from low-income settings is, however, limited. Sri Lanka is internationally acknowledged as a model amongst low-income countries for its maternal and child health statistics. Yet, very little research has considered the perspectives and experiences of the key front line health providers for pregnant women in Sri Lanka, public health midwives (PHMs). We address this gap by consulting PHMs about their experiences identifying and responding to pregnant women affected by domestic violence in an underserved area: the tea estate sector of Badulla district. Over two months in late 2014, our interdisciplinary team of social scientists and medical doctors met with 31 estate PHMs for group interviews and a participatory workshop at health clinics across Badulla district. In the paper, we propose a modified livelihoods model to conceptualise the physical, social and symbolic assets, strategies and constraints that simultaneously enable and limit the effectiveness of community-based health care responses to domestic violence. Our findings also highlight conceptual and practical strategies identified by PHMs to ensure improvements in this complex landscape of care. Such strategies include estate-based counselling services; basic training in family counselling and mediation for PHMs; greater surveillance of abusive men's behaviours by male community leaders; and performance evaluation and incentives for work undertaken to respond to domestic violence. The study contributes to international discussions on the meanings, frameworks, and identities constructed at the local levels of health care delivery in the global challenge to end domestic violence. In turn, such knowledge adds to international debates on the roles and responsibilities of health care professionals in responding to and preventing domestic violence.

Opinions and Experiences of Primary Healthcare Providers Regarding Violence against Women: a Systematic Review of Qualitative Studies

“…Limited consultation time, high workload and competing priorities, high staff turnover and lack of personal safety were other factors that obstructed the disclosure process (Infanti et al 2015;Iverson et al 2013;McCall-Hosenfeld et al 2014;Taft et al 2004;Salcedo-Barrientos et al 2011;Usta et al 2014;Visentin et al 2015;Taynan Sousa Porto et al 2014;Salgado Diez 2012). Moreover, some PCPs were reluctant to record VAW due to a lack of privacy and confidentiality at their primary care settings (Cox et al 2001;Peckover 2003): "I always write down a different cause for the IPV symptoms I treat, even in confirmed cases.…”

“…Furthermore, sometimes the majority of PCPs felt helpless, frustrated, impotent, powerless and unable to help or respond to VAW; in consequence they lacked the confidence to deal with VAW (Cox et al 2001;De Oliveira and Godoy Serpa 2007;De Oliveira Gomes et al 2015;Kohler et al 2013;Papadakaki et al 2014;Infanti et al 2015;Signorelli et al 2013;Silva et al 2015;Vieira et al 2013;Visentin et al 2015;Webster et al 2006;Williston and Lafreniere 2013): "Sometimes myself I get depressed and frustrated, I don't know what to do… sometimes you ask yourself, did I do the right thing or not? Did I help or did I make it worse?"…”

“…The main facilitator for disclosing VAW was to provide a compassionate and supportive response to women through establishing a trusting relationship and bond with them, by creating spaces of dialogue with an attentive non-judgmental listening, respect, and empathy (Bradbury-Jones and Taylor 2013; Cocco da Costa and Marques Lopes 2012; Cox et al 2001;Salgado Diez 2012;Djikanovic et al 2010;Silva et al 2015;Gomes et al 2014a;Hesler et al 2013;Hughes 2010;Infanti et al 2015;Pereira Gomes et al 2013;Signorelli et al 2013;Usta et al 2014;Vieira et al 2013;Visentin et al 2015;Williston and Lafreniere 2013). This involves an understanding of women's decision-making processes, acknowledging their power and autonomy, offering care and emotional support while examining the impact of PCPs' owns feelings and healthcare practice style: "I think it's just trying to remain supportive of where they are at.…”

“…Participating in the life of the community and creating a bond was also mentioned as a facilitator, especially for community health workers (Infanti et al 2015;Silva et al 2015). Health promotion actions (McCall-Hosenfeld et al 2014;Pereira Gomes et al 2013; Cocco da Costa and Marques Lopes 2012) or routine screening programs (Iverson et al 2013;Kohler et al 2013) were strategies that facilitated VAW detection for some PCPs.…”

Improving Safety Among Pregnant Women Reporting Domestic Violence in Nepal—A Pilot Study

“…In a routine ANC setting this would or should be done by health care providers. A qualitative study of public health midwives in Sri Lanka revealed that midwives acknowledged their unique status as trusted health providers in the communities and apply creative strategies (threaten abusive husbands, show images of babies born with deformities) to address DV among pregnant women [38].…”