Interventions in sexual and reproductive health services addressing violence against women in low-income and middle-income countries: a mixed-methods systematic review.

OBJECTIVES: To synthesise evidence on the effectiveness, cost-effectiveness and barriers to responding to violence against women (VAW) in sexual and reproductive health (SRH) services in low/middle-income countries (LMICs). DESIGN: Mixed-methods systematic review. DATA SOURCES: Medline, Embase, Psycinfo, Cochrane, Cinahl, IMEMR, Web of Science, Popline, Lilacs, WHO RHL, ClinicalTrials.gov, Google, Google Scholar, websites of key organisations through December 2019. ELIGIBILITY CRITERIA: Studies of any design that evaluated VAW interventions in SRH services in LMICs. DATA EXTRACTION AND SYNTHESIS: Concurrent narrative quantitative and thematic qualitative syntheses, integration through line of argument and mapping onto a logic model. Two reviewers extracted data and appraised quality. RESULTS: 26 studies of varied interventions using heterogeneous outcomes. Of ten interventions that strengthened health systems capacity to respond to VAW during routine SRH consultation, three reported no harm and reduction in some types of violence. Of nine interventions that strengthened health systems and communities' capacity to respond to VAW, three reported conflicting effects on re-exposure to some types of VAW and mixed effect on SRH. The interventions increased identification of VAW but had no effect on the provision (75%-100%) and uptake (0.6%-53%) of referrals to VAW services. Of seven psychosocial interventions in addition to SRH consultation that strengthened women's readiness to address VAW, four reduced re-exposure to some types of VAW and improved health. Factors that disrupted the pathway to better outcomes included accepting attitudes towards VAW, fear of consequences and limited readiness of the society, health systems and individuals. No study evaluated cost-effectiveness. CONCLUSIONS: Some VAW interventions in SRH services reduced re-exposure to some types of VAW and improved some health outcomes in single studies. Future interventions should strengthen capacity to address VAW across health systems, communities and individual women. First-line support should be better tailored to women's needs and expectations. PROSPERO REGISTRATION NUMBER: CRD42019137167.

Rape survivors in South Africa: analysis of the baseline socio-demographic and health characteristics of a rape cohort.

BACKGROUND: Little is known about women who have experienced a recent rape, and how they differ from women without this exposure. Identifying factors linked to rape is important for preventing rape and developing effective responses in countries like South Africa with high levels of sexual violence. OBJECTIVE: To describe the socio-demographic and health profile of women recently exposed to rape and to compare them with a non-rape-exposed group. METHODS: The Rape Impact Cohort Evaluation Study (RICE) enrolled 852 women age 16-40 years exposed to rape from post-rape care centres in Durban (South Africa) and a control group of 853 women of the same age range who have never been exposed to rape recruited from public health services. Descriptive analyses include logistic regression modelling of socio-demographic characteristics associated with recent rape exposure. RESULTS: Women with recent rape reported poorer health and more intimate partner violence than those who were not raped. They had a lower likelihood of having completed school (Odds Ratio [OR] 0.46 95% Confidence Interval (CI): 0.24-0.87) and dependence on a government grant as a main source of income (OR 0.61: 95%CI 0.49-0.77). They were more likely to live in informal housing (OR 1.88 95%CI: 1.43-2.46) or rural areas (OR 2.24: 95%CI 1.61-3.07) than formal housing areas - however they were also more likely to report full-time employment (OR 4.24: 95%CI 2.73-6.57). CONCLUSION: The study shows that structural factors, such as lower levels of education, poverty, and living in areas of poor infrastructure are associated with women's vulnerability to rape. It also shows possible protection from rape afforded by the national financial safety net. It highlights the importance of safe transportation in commuting to work. Preventing rape is critical for enabling women's full social and economic development, and structural interventions are key for reducing women's vulnerability.