Objective To assess the effectiveness of a counselling intervention in antenatal care settings for pregnant women who report domestic violence.Design Pre-experimental study with pretest-posttest design.Settings Two public hospitals in Mumbai, India.Sample In all, 2778 pregnant women accessing antenatal care (ANC) in the hospitals from February to November 2016 were approached for study participation; 2515 women consented. These women were screened by trained counsellors for domestic violence during pregnancy (domestic violence during pregnancy). Domestic violence during pregnancy was reported by 16.2% (408) of women. Of these, 155 women sought counselling services. Postintervention analyses were carried out with 142 women at 6 weeks post-delivery; 13 women were not contactable.Methods The 442 women who reported domestic violence during pregnancy were provided a minimum of two counselling sessions by trained counsellors during their ANC visits. A counselling intake form was used to collect pre-and post-intervention data.Main outcome measures Prevalence of domestic violence during pregnancy, change in women's ability to cope, safety, and health.Results Prevalence of domestic violence during pregnancy (16.1%) was comparable to those of common obstetric complications routinely screened for during ANC. In all, 60-65% women reported cognitive changes such as recognising impact of violence and need to speak out against it. In all, 50.7% women took action at the individual level to address domestic violence during pregnancy. This change was not statistically significant (P-value 0.193). Of the women studied, 35.9% adopted at least one safety measure, and 84% of the women reported better health status post-intervention.Conclusions Routine enquiry and counselling for domestic violence during pregnancy are effective in improving women's ability to cope, safety, and health.

Background Violence against women [VAW] is an urgent public health issue and health care providers [HCPs] are in a unique position to respond to such violence within a multi-sectoral health system response. In 2013, the World Health Organization (WHO) published clinical and policy guidelines (henceforth – the Guidelines) for responding to intimate partner violence and sexual violence against women. In this practical implementation report, we describe the adaptation of the Guidelines to train HCPs to respond to violence against women in tertiary health facilities in Maharashtra, India. Methods We describe the strategies employed to adapt and implement the Guidelines, including participatory methods to identify and address HCPs’ motivations and the barriers they face in providing care for women subjected to violence. The adaptation is built on querying health-systems level enablers and obstacles, as well as individual HCPs’ perspectives on content and delivery of training and service delivery. Results The training component of the intervention was delivered in a manner that included creating ownership among health managers who became champions for other health care providers; joint training across cadres to have clear roles, responsibilities and division of labour; and generating critical reflections about how gender power dynamics influence women's experience of violence and their health. The health systems strengthening activities included establishment of standard operating procedures [SOPs] for management of VAW and strengthening referrals to other services. Conclusions In this intervention, standard training delivery was enhanced through participatory, joint and reflexive methods to generate critical reflection about gender, power and its influence on health outcomes. Training was combined with health system readiness activities to create an enabling environment. The lessons learned from this case study can be utilized to scale-up response in other levels of health facilities and states in India, as well as other LMIC contexts. Plain language summary Violence against women affects millions of women globally. Health care providers may be able to support women in various ways, and finding ways to train and support health care providers in low and middle-income countries to provide high-quality care to women affected by violence is an urgent need. The WHO developed Clinical and Policy Guidelines in 2013, which provide guidance on how to improve health systems response to violence against women. We developed and implemented a series of interventions, including training of health care providers and innovations in service delivery, to implement the WHO guidelines for responding to violence against women in 3 tertiary hospitals of Maharashtra, India. The nascent published literature on health systems approaches to addressing violence against women in low and middle-income countries focuses on the impact of these interventions. This practical implementation report focuses on the interventions themselves, describes the processes of developing and adapting the intervention, and thus provides important insights for donors, policy-makers and researchers.

Sexual violence within marriage is common and manifests in various forms, including marital rape. It has serious physical and mental health consequences and is a violation of women’s sexual and reproductive health rights. Marital rape, reproductive coercion, inserting objects in the vagina or anus, and withholding sexual pleasure are forms of violence routinely experienced by women. Based on service records of survivors coming to public hospitals in an Indian city, this paper presents their pathways to disclosure and institutional responses such as hospitals and police. The findings highlight that a large proportion of survivors of domestic violence confide having experienced forced sexual intercourse by the husband while sharing their experience of physical, economic, and emotional violence with crisis intervention counsellors. However, a small number of women do report marital rape to formal systems like hospitals and police. These systems respond inadequately to women reporting marital rape, as the rape law exempts rape by husband. Sexual violence within marriage can have serious health consequences, and a sensitive healthcare provider can create an enabling environment for disclosing abuse and providing relevant care and support. The paper argues that a necessary precondition to enable women to access health care and justice is to nullify “Exception 2 to Section 375 of the Indian Penal Code” This exception exempts rape by the husband from the purview of the rape law.

Background Violence against women is a serious public health concern, and is highly prevalent globally, including in India. Health-care providers [HCPs] can play an important role in addressing and reducing negative consequences of violence against women. We implemented a pre-post intervention study of HCP training in three tertiary care facilities in Maharashtra, India. Methods The study used a pre-post intervention design with assessment of HCPs’ (n = 201) knowledge, attitudes, perceived preparedness and practice at three time points: before training, after training and at 6 months follow- up. Results Total median score of knowledge about common signs and symptoms of violence (8.89 vs, 10.00), attitudes towards acceptability of violence (9.05 vs. 10.00), individual (6.74 vs. 10.00) and system level preparedness (6.11 vs. 8.14) improved from pre to post- training. The generalized estimating equation [GEE] model, adjusted for age, sex, site and department, showed an improvement in knowledge, attitudes and preparedness post- training. The change from pre to 6 months follow- up was not significant for attitude. Conclusions This package of interventions, including training of HCPs, improved HCPs’ knowledge, attitudes and practices, yet changes in attitudes and preparedness did not sustain over time. This study indicates feasibility and positive influence of a multi-component intervention to improve HCP readiness to respond to violence against women in a low-resource setting. Future phases of intervention development include adapting this intervention package for primary and secondary health facilities in this context, and future research should assess these interventions using a rigorous experimental design. Finally, these results can be used to advocate for multi-layered, systems-based approaches to strengthening health response to violence against women.

This commentary focuses on “intangible software”, defined as the range of ideas, norms, values and issues of power or trust that affect the performance of health systems. While the need to work with intangible software within health systems is increasingly being recognized, the practical hows of doing so have been given less attention. In this commentary, we, a team of researchers and implementers from India, have tried to deliberate on these hows through a practice lens. We engage with four questions of current relevance to intangible software in the field of health policy and systems research (HPSR): (1) Is it possible to rewire intangible software in health systems? (2) What approaches have been attempted in the Indian public health system to rewire intangibles? (3) Have such approaches been evaluated? (4) What practical lessons can we offer from our experience on rewiring intangibles? From our perspective, approaches to rewiring intangible software recognize that people in health systems are capable of visioning, thinking, adapting to and leading change. These approaches attempt to challenge the often-unchallenged power hierarchies in health systems by allowing people to engage deeply with widely accepted norms and routinized actions. In this commentary, we have reported on such approaches from India under six categories: approaches intended to enable visioning and leading; approaches targeted at engaging with evidence better; approaches intended to help health workers navigate contextual complexities; approaches intended to build the cultural competence; approaches that recognize and reward performance; and approaches targeted at enabling collaborative work and breaking power hierarchies. Our collective experiences suggest that intangible software interventions work best when they are codesigned with various stakeholders, are contextually adapted in an iterative manner and are implemented in conjunction with structural improvements. Also, such interventions require long-term investments. Based on our experiences, we highlight the need for the following: (1) fostering more dialogue on this category of interventions among all stakeholders for cross-learning; (2) evaluating and publishing evidence on such interventions in nonconventional ways, with a focus on participatory learning; and (3) building ecosystems that allow experiential learnings on such interventions to be shared.