BackgroundThe paper explores how age, social position or class, and linguistic and cultural background intersect and place women in varying positions of control and vulnerability to obstetric violence in state health institutions in Colombo district, Sri Lanka. Obstetric violence occurs during pregnancy, childbirth and the immediate postpartum period; hence, it is violence that directly affects women. The authors aim to break the traditional culture of silence around obstetric violence and bring attention to the resulting implications for quality of care and patient trust in obstetric care facilities or providers.MethodsFive focus group discussions were held with 28 public health midwives who had prior experience working in labor rooms. Six focus group discussions were held with 38 pregnant women with previous childbirth experience. Additionally, 10 of the 38 women, whom felt they had experienced excessive pain, fear, humiliation, and/or loss of dignity as patients in labor, participated in individual in-depth interviews. An intersectional framework was used to group the qualitative data into categories and themes for analysis.ResultsObstetric violence appears to intersect with systems of power and oppression linked to structural gender, social, linguistic and cultural inequities in Sri Lanka. In our dataset, younger women, poorer women, and women who did not speak Sinhala seemed to experience more obstetric violence than those with relevant social connections and better economic positions. The women in our study rarely reported obstetric violence to legal or institutional authorities, nor within their informal social support networks. Instead, they sought obstetric care, particularly for childbirth, in other state hospitals in subsequent pregnancies.ConclusionsThe quality of obstetric care in Sri Lanka needs improvement. Amongst other initiatives, policies and practices are required to sensitize health providers about the existence of obstetric violence, and repercussions are required for abusive or discriminatory practices. The ethics of care should be further reinforced in the professional training of obstetric health providers.

BackgroundGlobally, knowledge of health sector options to respond to domestic violence during pregnancy is increasing, but this topic is under-investigated in Nepal. This gap affects the provision of adequate antenatal care services and understanding of factors that influence women’s willingness and ability to use available services. It is critical to know more about the social norms in a community that promote and prevent women experiencing domestic violence from seeking antenatal care.ObjectiveTo explore community perceptions of domestic violence against pregnant women.MethodsA qualitative study was conducted in Dhulikhel municipality, involving 41 men and 76 women in 12 focus group discussions in different gender and family role separated groups. The interviews were recorded, transcribed in verbatim, and analyzed using content analysis. A socio-ecological model was used as a theoretical framework to illustrate linkages between individual, relationship, community, and societal influences on perceptions of domestic violence during pregnancy.ResultsThe community recognized different forms of violence during pregnancy threatening women’s physical and psychological health and presenting obstacles to seeking antenatal care. Some types of culturally specific violence were considered particularly harmful, such as pressure to give birth to sons, denial of food, and forcing pregnant women to do hard physical work during pregnancy, which may leave daughters-in-law vulnerable to domestic violence in extended families. A culture where violence is normalized and endurance and family reconciliation are promoted above individual health was perceived to cause women to tolerate and accept the situation. Participants suggested actions and strategies to address continuing violence, which indicated a societal transition toward increased awareness and changing attitudes and practices.ConclusionsDomestic violence during pregnancy needs to be addressed at different levels in Nepal, where women are often dependent on others for access to health care. Social norms were perceived to be shifting toward reduced acceptance of violence against women, but restrictions on women’s life options, movement, and decision-making authority were still considered impediments to pregnant women’s health.

BackgroundGestational diabetes mellitus (GDM) is a risk factor for the development of type 2 diabetes. Lifestyle intervention can prevent progression to type 2 diabetes in high risk populations. We designed a randomised controlled trial (RCT) to evaluate the effectiveness of an established lifestyle intervention compared to standard care for delaying diabetes onset in European women with recent GDM. Recruitment into the RCT was more challenging than anticipated with only 89 of 410 (22%) women agreeing to participate. This paper identifies factors that could enhance participation of the target population in future interventions.MethodsWe hypothesised that women who agreed to participate would have higher diabetes risk profiles than those who declined, and secondly that it would be possible to predict participation on the bases of those risk factors. To test our hypothesis, we identified the subset of women for whom we had comprehensive data on diabetes risks factors 3-5 years following GDM, reducing the sample to 43 participants and 73 decliners. We considered established diabetes risk factors: smoking, daily fruit and vegetable intake, participation in exercise, family history of diabetes, glucose values and BMI scores on post-partum re-screens, use of insulin during pregnancy, and age at delivery. We also analysed narrative data from 156 decliners to further understand barriers to and facilitators of participation.ResultsTwo factors differentiated participants and decliners: age at delivery (with women older than 34 years being more likely to participate) and insulin use during pregnancy (with women requiring the use of insulin in pregnancy less likely to participate). Binary logistic regression confirmed that insulin use negatively affected the odds of participation. The most significant barriers to participation included the accessibility, affordability and practicality of the intervention.ConclusionsWomen with recent GDM face multiple barriers to lifestyle change. Intervention designers should consider: (i) the practicalities of participation for this population, (ii) research designs that capitalise on motivational differences between participants, (iii) alleviating concerns about long-term diabetes management. We hope this work will support future researchers in developing interventions that are more relevant, effective and successful in recruiting the desired population.Trial registrationCurrent Controlled Trials ISRCTN41202110

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.

Objective: Previous gestational diabetes (GDM) is associated with a significant lifetime risk of type 2 diabetes. In this study, we assessed the performance of HbA1c and fasting plasma glucose (FPG) measurements against that of 75 g oral glucose tolerance testing (OGTT) for the follow-up screening of women with previous GDM. Methods: Two hundred and sixty-six women with previous GDM underwent the follow-up testing (mean of 2.6 years (S.D. 1.0) post-index pregnancy) using HbA1c (100%), and 75 g OGTT (89%) or FPG (11%). American Diabetes Association (ADA) criteria for abnormal glucose tolerance were used. Design, cohort study, and results: The ADA HbA1c high-risk cut-off of 39 mmol/mol yielded sensitivity of 45% (95% CI 32, 59), specificity of 84% (95% CI 78, 88), negative predictive value (NPV) of 87% (95% CI 82, 91) and positive predictive value (PPV) of 39% (95% CI 27, 52) for detecting abnormal glucose tolerance. ADA high-risk criterion for FPG of 5.6 mmol/l showed sensitivity of 80% (95% CI 66, 89), specificity of 100% (95% CI 98, 100), NPV of 96% (95% CI 92, 98) and PPV of 100% (95% CI 91, 100). Combining HbA1c R39 mmol/mol with FPG R5.6 mmol/l yielded sensitivity of 90% (95% CI 78, 96), specificity of 84% (95% CI 78, 88), NPV of 97% (95% CI 94, 99) and PPV of 56% (95% CI 45, 66). Conclusions: Combining test cut-offs of 5.6 mmol/l and HbA1c 39 mmol/mol identifies 90% of women with abnormal glucose tolerance post-GDM (mean 2.6 years (S.D.1.0) post-index pregnancy). Applying this follow-up strategy will reduce the number of OGTT tests required by 70%, will be more convenient for women and their practitioners, and is likely to lead to increased uptake of long-term retesting by these women whose risk for type 2 diabetes is substantially increased.

Background : Sexual harassment occurs within the nursing profession globally, challenging the health and safety of nurses and the quality and efficiency of health systems. In Sri Lanka, no studies have explored this issue in the health sector; however, female employees face sexual harassment in other workplace settings. Objective : To explore female nurses’ perceptions of workplace sexual harassment in a large state hospital in Sri Lanka. Methods : This is a qualitative study conducted in an urban, mainly Buddhist and Singhalese context. We invited all female senior and ward nurses working in the hospital to participate in the study. We conducted individual in-depth interviews with four senior nurses and focus group discussions with 29 nurses in three groups. Results : The nurses described a variety of perceived forms of sexual harassment in the hospital. They discussed patient-perpetrated incidents as the most threatening and the clearest to identify compared with incidents involving doctors and other co-workers. There was significant ambiguity regarding sexual consent and coercion in relationships between female nurses and male doctors, which were described as holding potential for exploitation or harassment. The nurses reported that typical reactions to sexual harassment were passive. Alternatively, they described encountering inaction or victim blaming when they attempted to formally report incidents. They perceived that workplace sexual harassment has contributed to negative societal attitudes about the nursing profession and discussed various informal strategies, such as working in teams, to protect themselves from sexual harassment in the hospital. Conclusions : Sexual harassment was a perceived workplace concern for nurses in this hospital. To develop effective local prevention and intervention responses, further research is required to determine the magnitude of the problem and explore differences in responses to and consequences of sexual harassment based on perpetrator type and intent, and personal vulnerabilities of the victims, among other factors.

Background Domestic violence is one of the most common forms of violence against women. Domestic violence during pregnancy is associated with adverse perinatal and maternal outcomes. We aimed to assess whether domestic violence was associated with mode of delivery, low birthweight and preterm birth in two sites in Nepal. Methods In this prospective cohort study we consecutively recruited 2004 pregnant women during antenatal care at two hospitals between June 2015 and September 2016. The Abuse Assessment Screen (modified) was used to assess fear and violence. Having ever experienced either fear or violence was defined as any domestic violence. Obstetric outcomes were obtained from hospital records for 1381 (69%) women, selecting singleton pregnancies only. Mode of delivery was assessed as birth by cesarean section or not. A birthweight of less than 2500 g was defined as low birthweight and preterm birth as birth before completion of 37 weeks gestation. Descriptive and multiple logistic regression analyses were performed to assess associations. Results Twenty percent of the women reported any domestic violence. Among all 1381 women, 37.6% gave birth by cesarean section. Of those women who delivered by cesarean section, 84.7% had an emergency cesarean section. Less than 10% of the babies were born prematurely and 13.5% were born with low birthweight. We found no significant association between exposure to any domestic violence during pregnancy and risk of a low birthweight baby or birth by cesarean section. However, having experienced both violence and fear was significantly associated with giving birth to a preterm infant [aOR 2.33 (95% CI;1.10–4.73)]. Conclusions Domestic violence is common in Nepal. This is a potential risk factor for severe morbidity and mortality in newborns. We found that the risk of having a preterm baby was higher for pregnant women who experienced both fear and violence. This should be recognized by the health sector. In this study, no significant differences were found in the rate of cesarean section nor low birthweight for women who had experienced any domestic violence compared to those who did not. Electronic supplementary material The online version of this article (10.1186/s12889-019-6967-y) contains supplementary material, which is available to authorized users.

Obstetric violence refers to the mistreatment of women in pregnancy and childbirth care by their health providers. It is linked to poor quality of care, lack of trust in health systems, and adverse maternal and neonatal outcomes. Evidence of interventions to reduce and prevent obstetric violence is limited. We developed a training intervention using a participatory theatre technique called Forum Play inspired by the Theatre of the Oppressed for health providers in Sri Lanka. This paper assesses the potential of the training method to increase staff awareness of obstetric violence and promote taking action to reduce or prevent it. We conducted four workshops with 20 physicians and 30 nurses working in three hospitals in Colombo, Sri Lanka. Participants completed a questionnaire before and three-to-four months after the intervention. At follow-up, participants more often reported that they had been involved in situations of obstetric violence, indicating new knowledge of the phenomenon and/or an increase in their ability to conceptualise it. The intervention appears promising for improving the abilities of health care providers to recognise obstetric violence, the first step in counteracting it. The study demonstrates the value of developing further studies to assess the longitudinal impacts of theatre-based training interventions to reduce obstetric violence and, ultimately, improve patient care.