Table 4 WHO ethical and safety recommendations for research on violence against women

The safety of respondents and the research team is paramount, and should guide all project decisions.

Given the study topic, it is possible that participants and/or the research team can be put at risk of negative or retaliatory responses. In order to reduce this risk, the study, objectives and activities are framed neutrally as a study of women’s experiences of how they are treated during childbirth. This description will be used by research teams to describe the study to others in facilities or in communities, if required.

Prevalence studies need to be methodologically sound and to build upon current research experience about how to minimize the under-reporting of violence.

We have consulted extensively with other researchers on violence against women and mistreatment of women during childbirth to ensure that the study is as methodologically rigorous as possible. In this study women will be asked to disclose information on difficult or painful experiences. Women may feel that these events are too personal, embarrassing or shameful to discuss or feel at risk of reprisal. They may also not recall the event or feel it was not significant. The discussion guides will avoid the use of loaded terms, such as ‘rape’ or ‘violence’ and leading questions regarding how women were treated. The discussion guides will be designed so as to give women multiple opportunities to disclose events of mistreatment or violence during the course of the interview. Adult female interviewers who are not healthcare providers will be sought for the IDIs and FGDs with women in order to enhance women’s disclosure of mistreatment. Interviewers will be carefully selected and appropriately trained in performing the interview, with adequate time and support for piloting and pre-testing the discussion guide. Interviewers will not be permitted to conduct interviews in their own community, or with women known to them.

Protecting confidentiality is essential to ensure both women’s safety and data quality.

In order to ensure confidentiality, the following measures will be taken: (a) all interviewers will receive strict instructions and training on the importance of maintaining confidentiality; (b) participant numbers only will be used to identify women on any study forms; and (c) data will be presented in an aggregated, de-identified manner that does not identify specific women, households or facilities.

All research team members should be carefully selected and receive specialized training and on-going support.

Specialized training will be prepared and provided to all individuals in research teams, focusing on key concepts of mistreatment of women during childbirth. This training will include opportunities to discuss biases, fears and stereotypes, as well as (if relevant) their own experiences during birth. Researchers will be free to withdraw from the project without prejudice. During the data collection phases, regular debriefing meetings will be pre-scheduled to allow the research team to discuss their experiences, feelings and reactions to the study activities. These meetings are intended to reduce stress associated with fieldwork, allow reflection on individual experiences, and identify any possible safety or health concerns that research team members have and avert negative consequences.

The study design must include actions aimed at reducing any possible distress caused to the participants by the research.

Interviewers will be trained to maintain a supportive, non-judgmental manner when conducting interviews, e.g. asking questions in a neutral tone. They will also be trained to anticipate the effect questions may have on the respondent, how to respond to a woman’s level of distress and to recognize the need to terminate an interview if the subject matter becomes too negative. For example, if a woman has had a particularly negative birth experience, it may cause her an emotional distress, necessitating termination of the interview. The discussion will conclude in a positive manner. These standards will be achieved through role-playing activities (observed by trainers) during training.

Fieldworkers should be trained to refer women requesting assistance to available local services and sources of support. Where few resources exist, it may be necessary for the study to create short-term support mechanisms.

Participants in the study may have experienced such mistreatment that they will require additional assistance during or following an interview. In consultation with local research team and local organizations, the research team will identify existing local support services. Once the relevant local services will be identified, they will be contacted and informed of the study, and permission for referral for support obtained.

Researchers and donors have an ethical obligation to help ensure that their findings are properly interpreted and used to advance policy and intervention development.

Findings from this research will be prepared as scientific manuscripts and submitted for publication. Every effort will be made to disseminate and communicate the research findings via formal and informal media locally, nationally and globally. Research findings will also be communicated through WHO and reproductive health research networks. Research findings will be used to inform and strengthen existing advocacy efforts and networks working on women’s rights, reproductive rights and reducing mistreatment of women during childbirth.

Violence questions should only be incorporated into surveys designed for other purposes when ethical and methodological requirements can be met.

The findings from this study will inform the development of tools, for the purposes of measuring mistreatment of women during childbirth.