Helping or heightening vulnerability? Midwives as arbiters of risk for women experiencing self-directed violence in urban Sri Lanka

The response of midwives to women engaging in self-directed violence (SDV) may affect women’s care and outcomes. The author explored midwives’ understanding of SDV through semi-structured focus groups and in-depth interviews with 11 Public Health Midwives in urban Sri Lanka. Thematic analysis identified four key themes: (a) perceived dimensions of women’s risk and vulnerability to SDV, (b) midwives as arbiters of risk, (c) representations of women engaging in SDV, and (d) midwives’ perceived capacity to respond. Given their proximity to communities, trustworthiness as sites of disclosure, and respectability as women and guardians of ideal womanhood in Sri Lankan society, midwives occupy a powerful position in the health system through which to alleviate or reinforce women’s risk to SDV. Yet, investment in developing their skills and role to respond to the growing phenomenon of SDV among women in Sri Lanka must consider the context within which midwives assess and select their responses

Trajectories of self-directed violence amongst women of reproductive age in Sri Lanka

This thesis contributes to an understanding of the scale of different dimensions of selfdirected violence (SDV) amongst women of reproductive age and the trajectories through which women engage in them, by presenting findings of primary and secondary data collected through extensive mixed-methods fieldwork in Sri Lanka. It responds to the marginalisation of the female experience and the fuller spectrum of SDV, as research has disproportionately invested in understanding the extreme outcome of suicide through a male lens. Focused in one western district, it capitalised on women’s attendance at antenatal services to isolate the prevalence of SDV amongst reproductive age women both before and during pregnancy and its potential correlates using innovative screening measures (n = 1000). Complementing this sub-focus on perinatal women, women’s core health service provider – Public Health Midwives (n = 11) – shared in-depth accounts of their experiences of and responses to managing women’s SDV. Establishment of a prospective surveillance system in Sri Lanka’s second largest public hospital yielded data on trends in women’s non-fatal self-harm and first-person accounts of women’s pathways to a medically serious event (n = 210); analyses of in-depth interviews with 17 women are presented. Active case finding of known suicides in the district allowed for reflection on the current medicolegal system generating suicide data in this context as well as the insights of 32 women’s deaths based on these archival data. The findings of this thesis highlight high levels of mental distress, (intimate partner) violence and lifetime prevalence of SDV in Sri Lankan women. The particularities of women’s gendered position in Sri Lankan society observed throughout this thesis such as sexual and reproductive health and rights, exposure to violence and expectations to embody respectable womanhood, emphasise the value of employing a gendered perspective to assess women’s risk of self-directed violence and inform future policy and prevention efforts

Adolescent perinatal mental health in South Asia and Sub-Saharan Africa: A systematic review of qualitative and quantitative evidence.

Despite the contribution of mental ill-health to perinatal morbidity and mortality, the experiences of adolescent girls and young women (AGYW) in low- and middle-income countries remain overlooked. This review explores potential intersecting vulnerabilities for perinatal mental health to identify the prevalence, risk factors, interventions, and implications for health services and future research. We searched mixed-methods English-language studies in four databases (MEDLINE, PsycInfo, Global Health, Embase) published between January 1, 2000 and April 30, 2022 reporting age-disaggregated data on the prevalence, risk factors, and interventions for AGYW's mental health during pregnancy through one year postpartum (quantitative) and/or the mental health experiences of AGYW in the perinatal period (qualitative). Our search yielded 3205 results, of which 48 met the inclusion criteria. Both regions observe a paucity of robust evidence and intervention evaluations, particularly South Asia. While meta-analysis was infeasible due to study heterogeneity, quantitative studies do identify individual-level risk factors for perinatal depression. Qualitative studies emphasise stigma's impact, among other societal-level social risk factors, on diverse perinatal mental health outcomes of importance to AGYW themselves. Rigorous evaluations of interventions are lacking bar two protocols with forthcoming results. Evidence gaps persist concerning prevalence of outcomes beyond depression and implications of AGYW's perinatal experiences including pregnancy/perinatal loss and obstetric and postpartum complications. High-quality research, including comparable prevalence and multi-method evidence identifying risk and protective factors and promising interventions is urgently needed to improve adolescent wellbeing in the perinatal period. A key strength of this review is our assessment of available evidence for both regions. In doing so, we address a critical blind spot of prior reviews that focused either on adult perinatal mental health in low- and middle-income countries, or on AGYW perinatal mental health in high-income settings but neglected the intersection of these potential vulnerabilities for these high-burden, low-resource contexts

Suicide and poverty in low-income and middle-income countries: a systematic review

Suicide is the 15th leading cause of death worldwide, with over 75% of suicides occurring in low- and middle-income countries where most of the world’s poor live. Nonetheless, evidence on the relationship between suicide and poverty in low- and middle-income countries is limited. We conducted a systematic review to understand the relationship between suicidal ideations and behaviours (SIB) and economic poverty in low- and middle-income countries. We identified 37 studies meeting inclusion criteria. In 18 studies reporting the relationship between completed suicide and poverty, 31 relationships were explored. The majority reported a positive association. Of the 20 studies reporting on the relationship between non-fatal SIB and poverty, 36 relationships were explored. Again, the majority of studies reported a positive relationship. However, when considering each poverty dimension separately, we found substantial variations. Findings suggest a relatively consistent trend at the individual level indicating that poverty, particularly in the form of worse economic status, diminished wealth and unemployment is associated with SIB. At the country level, there are insufficient data to draw clear conclusions. Available evidence suggests potential benefits in addressing economic poverty within suicide prevention strategies, with attention to both chronic poverty and acute economic events

What Women Want: Mental Health in the Context of Violence Against Women in Sri Lanka—A Qualitative Study of Priorities and Capacities for Care

Insufficient evidence guides mental health service development for survivors of violence against women in Sri Lanka. Provider and survivor perspectives on (1) what constitutes mental health, (2) quality of care, and (3) priority areas and stakeholders for intervention were identified through framework analysis of 53 in-depth interviews. Desired care is chiefly psychosocial—not psychological—prioritizing socioeconomic, parenting, and safe environment needs in non-clinical community settings. Our evidence points strongly to the need to strengthen non-mental health community-based providers as “first contacts” and reassessment of health system-centric interventions which neglect preferred community responses and more holistic approaches accounting for women's full circumstances

Mental health of women and children experiencing family violence in conflict settings: a mixed methods systematic review.

Background Armed conflict has significant impacts on individuals and families living in conflict-affected settings globally. Scholars working to prevent violence within families have hypothesised that experiencing armed conflict leads to an increase in family violence and mental health problems. In this review, we assessed the prevalence of family violence in conflict settings, its association with the mental health of survivors, moderating factors, and the importance of gender relations. Methods Following PRISMA guidelines, we systematically reviewed quantitative and qualitative studies that assessed the prevalence of family violence and the association between family violence and mental health problems, within conflict settings (PROSPERO reference CRD42018114443). Results We identified 2605 records, from which 174 full text articles were screened. Twenty-nine studies that reported family violence during or up to 10 years after conflict were eligible for inclusion. Twenty one studies were quantitative, measuring prevalence and association between family violence and mental health problems. The studies were generally of high quality and all reported high prevalence of violence. The prevalence of violence against women was mostly in the range of 30-40%, the highest reported prevalence of physical abuse being 78.9% in Bosnia and Herzegovina. For violence against children, over three-quarters had ever experienced violence, the highest prevalence being 95.6% in Sri Lanka. Associations were found with a number of mental health problems, particularly post-traumatic stress disorder. The risk varied in different locations. Eight qualitative studies showed how men's experience of conflict, including financial stresses, contributes to their perpetration of family violence. Conclusions Family violence was common in conflict settings and was associated with mental health outcomes, but the studies were too heterogenous to determine whether prevalence or risk was greater than in non-conflict settings. The review highlights an urgent need for more robust data on perpetrators, forms of family violence, and mental health outcomes in conflict-affected settings in order to help understand the magnitude of the problem and identify potential solutions to address it

Cultivating capacities in community-based researchers in low-resource settings: Lessons from a participatory study on violence and mental health in Sri Lanka

Participatory methods, which rely heavily on community-based data collectors, are growing in popularity to deliver much-needed evidence on violence and mental health in low- and middle-income countries. These settings, along with local researchers, encounter the highest burden of violence and mental ill-health, with the fewest resources to respond. Despite increased focus on wellbeing for research participants and, to a lesser degree, professional researchers in such studies, the role-specific needs of community-based researchers receive scant attention. This co-produced paper draws insights from one group’s experience to identify rewards, challenges, and recommendations for supporting wellbeing and development of community-based researchers in sensitive participatory projects in low-resource settings. Twenty-one community-based researchers supporting a mixed-methods study on youth, violence and mental health in Sri Lanka submitted 63 reflexive structured journal entries across three rounds of data collection. We applied Attride-Stirling’s method for thematic analysis to explore peer researchers’ learning about research, violence and mental health; personal-professional boundaries; challenges in sensitive research; and experiences of support from the core team. Sri Lanka’s first study capturing experiences of diverse community-based researchers aims to inform the growing number of global health and development actors relying on such talent to deliver sensitive and emotionally difficult work in resource-limited and potentially volatile settings. Viewing participatory research as an opportunity for mutual learning among both community-based and professional researchers, we identify practice gaps and opportunities to foster respectful team dynamics and create generative and safe co-production projects for all parties. Intentional choices around communication, training, human and consumable resources, project design, and navigating instable research conditions can strengthen numerous personal and professional capacities across teams. Such individual and collective growth holds potential to benefit short- and long-term quality of evidence and inform action on critical issues, including violence and mental health, facing high-burden, low-resource contexts