A research agenda to improve incidence and outcomes of assisted vaginal birth.

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth.

L'accès aux soins obstétriques d'urgence, y compris l'accouchement vaginal assisté et la césarienne, est essentiel pour améliorer les effets de la maternité et de l'accouchement. Toutefois, bien que la proportion de césariennes ait augmenté ces dernières décennies, le recours à l'accouchement vaginal assisté a diminué. C'est particulièrement le cas dans les pays à revenu faible ou intermédiaire, bien que l'accouchement vaginal assisté soit souvent moins risqué qu'une césarienne. Nous avons donc mené un processus en trois étapes afin d'imaginer un programme de recherche qui permettrait d'augmenter le recours à l'accouchement vaginal assisté ou de le réintroduire. Après avoir réalisé une synthèse des données probantes, qui a servi de base à une consultation avec des experts techniques qui ont proposé un programme de recherche initial, nous avons sollicité et incorporé les avis des représentantes des femmes pour ce programme. Ce processus nous a permis d'imaginer un programme de recherche complet, avec des sujets classés comme suit: (i) la nécessité de comprendre la perception qu'ont les femmes de l'accouchement vaginal assisté et de fournir des informations appropriées et fiables; (ii) l'importance de la formation des prestataires de soins de santé en matière de compétences cliniques, mais aussi de respect dans les soins de santé, de communication efficace, de prise de décision partagée et de consentement éclairé; ou (iii) les obstacles à la mise en œuvre et à la durabilité et les facteurs qui les facilitent. Les réactions de femmes nous ont appris qu'il était urgent de reconnaître que l'accouchement, la naissance et le post-partum sont des processus humains intrinsèquement physiologiques et dignes au cours desquels les interventions ne devraient être mises en œuvre qu'en cas de nécessité. La promotion et/ou la réintroduction de l'accouchement vaginal assisté dans les régions à faibles ressources nécessitent que les pouvoirs publics, les décideurs politiques et les administrations d'hôpitaux soutiennent les prestataires de soins de santé qualifiés, qui pourront à leur tour soutenir respectueusement les femmes pendant l'accouchement.

El acceso a la atención obstétrica de emergencia, incluido el parto vaginal asistido y el parto por cesárea, es crucial para mejorar los resultados de la maternidad y el parto. No obstante, aunque el porcentaje de partos por cesárea ha aumentado en las últimas décadas, el uso del parto vaginal asistido ha disminuido. Esto ocurre especialmente en los países de ingresos bajos y medios, a pesar de que un parto vaginal asistido suele ser menos arriesgado que un parto por cesárea. Por lo tanto, llevamos a cabo un proceso de tres pasos para identificar un programa de investigación necesario para aumentar el uso del parto vaginal asistido o volver a incorporarlo: tras realizar una síntesis de la evidencia, que sirvió de base para una consulta con expertos técnicos que propusieron un programa de investigación inicial, buscamos e integramos las opiniones de las representantes de las mujeres sobre este programa. Este proceso nos ha permitido identificar un programa de investigación exhaustivo, con temas categorizados como: (i) la necesidad de comprender las percepciones de las mujeres sobre el parto vaginal asistido, y proporcionar información adecuada y fiable; (ii) la importancia de formar a los profesionales sanitarios en habilidades clínicas, pero también en atención respetuosa, comunicación efectiva, toma de decisiones compartida y consentimiento informado; o (iii) las barreras y los facilitadores de la implementación y la sostenibilidad. A partir de las opiniones de las mujeres, nos enteramos de la urgente necesidad de reconocer las experiencias del parto, el alumbramiento y el posparto como procesos humanos inherentemente fisiológicos y dignos, en los que las intervenciones solo deben aplicarse si son necesarias. La promoción o la reincoporación del parto vaginal asistido en regiones de escasos recursos exige que los gobiernos, los responsables de formular políticas y los administradores de hospitales apoyen a los profesionales sanitarios capacitados que, a su vez, pueden ayudar a las mujeres en el trabajo de parto y el alumbramiento de manera respetuosa.

Towards achieving the family planning targets in the African region: a rapid review of task sharing policies.

BACKGROUND: Expanding access and use of effective contraception is important in achieving universal access to reproductive healthcare services, especially in low- and middle-income countries (LMICs), such as those in sub-Saharan Africa (SSA). Shortage of trained healthcare providers is an important contributor to increased unmet need for contraception in SSA. The World Health Organization (WHO) recommends task sharing as an important strategy to improve access to sexual and reproductive healthcare services by addressing shortage of healthcare providers. This study explores the status, successes, challenges and impacts of the implementation of task sharing for family planning in five SSA countries. This evidence is aimed at promoting the implementation and scale-up of task sharing programmes in SSA countries by WHO. METHODOLOGY AND FINDINGS: We employed a rapid programme review (RPR) methodology to generate evidence on task sharing for family planning programmes from five SSA countries namely, Burkina Faso, Cote d'Ivoire, Ethiopia, Ghana, and Nigeria. This involved a desk review of country task sharing policy documents, implementation plans and guidelines, annual sexual and reproductive health programme reports, WHO regional meeting reports on task sharing for family planning; and information from key informants on country background, intervention packages, impact, enablers, challenges and ways forward on task sharing for family planning. The findings indicate mainly the involvement of community health workers, midwives and nurses in the task sharing programmes with training in provision of contraceptive pills and long-acting reversible contraceptives (LARC). Results indicate an increase in family planning indicators during the task shifting implementation period. For instance, injectable contraceptive use increased more than threefold within six months in Burkina Faso; contraceptive prevalence rate doubled with declines in total fertility and unmet need for contraception in Ethiopia; and uptake of LARC increased in Ghana and Nigeria. Some barriers to successful implementation include poor retention of lower cadre providers, inadequate documentation, and poor data systems. CONCLUSIONS: Task sharing plays a role in increasing contraceptive uptake and holds promise in promoting universal access to family planning in the SSA region. Evidence from this RPR is helpful in elaborating country policies and scale-up of task sharing for family planning programmes.

RESUME: INTRODUCTION: L'élargissement de l'accès et de l'utilisation d'une contraception efficace est important pour parvenir à l'accès universel aux services de santé reproductive, en particulier dans les pays à revenu faible et intermédiaire, comme ceux de l'Afrique subsaharienne. L'insuffisance de prestataires de soins de santé qualifiés est un facteur important de l'augmentation des besoins non satisfaits en matière de contraception en Afrique subsaharienne. L'Organisation mondiale de la Santé (OMS) recommande le partage des tâches comme stratégie importante pour améliorer l'accès aux services de santé sexuelle et reproductive en s'attaquant à la pénurie des prestataires de soins de santé. Cette étude explore l'état des lieux, les réussites, les défis et les impacts de la mise en œuvre du partage des tâches pour la planification familiale dans cinq pays d'Afrique subsaharienne. Ces données factuelles visent à promouvoir la mise en œuvre et l'extension des programmes de partage des tâches dans les pays d'Afrique sub-saharienne par l'OMS. MéTHODOLOGIE ET RéSULTATS: Nous avons utilisé la méthodologie de la revue rapide des programmes (RPR) pour générer des données sur le partage des tâches pour les programmes de planification familiale de cinq pays d'Afrique subsaharienne, à savoir le Burkina Faso, la Côte d'Ivoire, l'Éthiopie, le Ghana et le Nigéria. Cela impliquait la revue documentaire des documents de politique nationale de partage des tâches, des plans de mise en œuvre et des directives, des rapports annuels sur les programmes de santé sexuelle et reproductive, des rapports des réunions régionales de l'OMS sur le partage des tâches pour la planification familiale; et des informations provenant des informateurs clés sur le contexte du pays, les programmes d'intervention, l'impact, les catalyseurs, les défis et les voies à suivre pour le partage des tâches pour la planification familiale. Les résultats indiquent principalement l'implication des agents de santé communautaires, des sages-femmes et des infirmières dans les programmes de partage des tâches avec une formation liée à l'approvisionnement de pilules contraceptives et de contraceptifs réversibles à longue durée d'action (LARC). Les résultats indiquent une augmentation des indicateurs de planification familiale pendant la période de mise en œuvre du partage des tâches. Par exemple, l'utilisation des contraceptifs injectables a plus que triplé en six mois au Burkina Faso; le taux de prévalence de la contraception a doublé avec une baisse de la fécondité totale et des besoins non satisfaits en matière de contraception en Éthiopie; et l'adoption du LARC a augmenté au Ghana et au Nigéria. Certains obstacles à la réussite de la mise en œuvre comprennent une faible rétention des prestataires de niveau inférieur, une documentation inadéquate et des systèmes peu performants de gestion des données. CONCLUSIONS: Le partage des tâches joue un rôle important dans l'augmentation de l'utilisation de la contraception et dans la promotion de l'accès universel à la planification familiale dans la région Afrique subsaharienne. Les données de ce RPR sont utiles pour l'élaboration des politiques nationales et l'intensification du partage des tâches pour les programmes de planification familiale. Correct and consistent use of contraceptives has been shown to reduce pregnancy and childbirth related maternal deaths and generally improve reproductive health. However, statistics show that many women of reproductive age in SSA who ought to be using contraceptives are not using them. As a result, high rates of maternal deaths from pregnancy or childbirth-related complications have been recorded in the region. One of the key barriers to accessing family planning in SSA is the shortage of healthcare providers. To address this problem, WHO recommends task sharing as an intervention to improve access and use of sexual and reproductive health services including family planning. While task sharing guidelines have been developed and disseminated in many SSA countries, limited evidence exists on their adoption, implementation and outcomes to promote scale-up. This study undertook a rapid programme review of evidence from policy documents, implementation plans and guidelines, annual sexual and reproductive health programme reports, regional meeting reports and key stakeholder reports on task sharing to explore the status, successes, challenges and impacts of the implementation of task sharing for family planning in five SSA countries: Burkina Faso, Cote d'Ivoire, Ethiopia, Ghana, and Nigeria. We found that task sharing programmes mainly involved community health workers, midwives and nurses. The intervention led to increased modern contraception access and use and general improvement in family planning indicators during the implementation periods. Some barriers to successful implementation of task sharing include poor retention of lower cadre providers, inadequate documentation, and poor data systems.

Development of the WHO Antenatal Care Recommendations Adaptation Toolkit: a standardised approach for countries.

BACKGROUND: Increasingly, WHO recommendations are defined by context-specific factors and WHO is developing strategies to ensure that recommendations are successfully adapted and implemented at country level. This manuscript describes the development of a toolkit to support governments to adapt the WHO recommendations on antenatal care (ANC) for a positive pregnancy experience for their context in a systematic manner. METHODS: The toolkit was developed in three steps. It was created with input from methodologists and regional implementation experts (Step 1) followed by a user-testing phase (Step 2), implemented during country stakeholder meetings. User testing consisted of stakeholder interviews that were transcribed, and data was categorised according to the content analysis method. Suggestions for toolkit improvement and issues identified during the interviews were assessed as serious, moderately serious or minor/cosmetic. RESULTS: A total of 22 stakeholders - comprising five Ministry of Health (MoH) consultants, four MoH policy-makers, and 13 advisors/implementers - from Burkina Faso, India, Rwanda and Zambia participated in user-testing interviews during stakeholder meetings held in each country between August 2018 and February 2019. Most stakeholders had a medical or nursing background and half were women. Overall, responses to the toolkit were positive, with all stakeholders finding it useful and desirable. User testing interviews highlighted four serious, four moderately serious and five minor/cosmetic issues to be managed. These were addressed in the final step (Step 3), an updated version of the WHO ANC Recommendations Adaptation Toolkit, comprised of two main components - a baseline assessment tool with spreadsheets for data entry and a Slidedoc®, a dual-purpose document for reading and presentation, outlining the qualitative data that shaped the women-centred perspective of the guidelines, accompanied by an instruction manual detailing the components' use. CONCLUSIONS: The WHO ANC Recommendations Adaptation Toolkit was developed to support countries to systematically adapt the WHO ANC recommendations for country contexts. Using this approach, similar tools can be developed to support guideline implementation across different health domains and the continuum of care.

Shortages of benzathine penicillin for prevention of mother-to-child transmission of syphilis: An evaluation from multi-country surveys and stakeholder interviews.

BACKGROUND: Benzathine penicillin G (BPG) is the only recommended treatment to prevent mother-to-child transmission of syphilis. Due to recent reports of country-level shortages of BPG, an evaluation was undertaken to quantify countries that have experienced shortages in the past 2 years and to describe factors contributing to these shortages. METHODS AND FINDINGS: Country-level data about BPG shortages were collected using 3 survey approaches. First, a survey designed by the WHO Department of Reproductive Health and Research was distributed to 41 countries and territories in the Americas and 41 more in Africa. Second, WHO conducted an email survey of 28 US Centers for Disease Control and Prevention country directors. An additional 13 countries were in contact with WHO for related congenital syphilis prevention activities and also reported on BPG shortages. Third, the Clinton Health Access Initiative (CHAI) collected data from 14 countries (where it has active operations) to understand the extent of stock-outs, in-country purchasing, usage behavior, and breadth of available purchasing options to identify stock-outs worldwide. CHAI also conducted in-person interviews in the same 14 countries to understand the extent of stock-outs, in-country purchasing and usage behavior, and available purchasing options. CHAI also completed a desk review of 10 additional high-income countries, which were also included. BPG shortages were attributable to shortfalls in supply, demand, and procurement in the countries assessed. This assessment should not be considered globally representative as countries not surveyed may also have experienced BPG shortages. Country contacts may not have been aware of BPG shortages when surveyed or may have underreported medication substitutions due to desirability bias. Funding for the purchase of BPG by countries was not evaluated. In all, 114 countries and territories were approached to provide information on BPG shortages occurring during 2014-2016. Of unique countries and territories, 95 (83%) responded or had information evaluable from public records. Of these 95 countries and territories, 39 (41%) reported a BPG shortage, and 56 (59%) reported no BPG shortage; 10 (12%) countries with and without BPG shortages reported use of antibiotic alternatives to BPG for treatment of maternal syphilis. Market exits, inflexible production cycles, and minimum order quantities affect BPG supply. On the demand side, inaccurate forecasts and sole sourcing lead to under-procurement. Clinicians may also incorrectly prescribe BPG substitutes due to misperceptions of quality or of the likelihood of adverse outcomes. CONCLUSIONS: Targets for improvement include drug forecasting and procurement, and addressing provider reluctance to use BPG. Opportunities to improve global supply, demand, and use of BPG should be prioritized alongside congenital syphilis elimination efforts.

The Botswana Medical Eligibility Criteria Wheel: Adapting a Tool to Meet the Needs of Botswana's Family Planning Program.

In efforts to strive for family planning repositioning in Botswana, the Ministry of Health convened a meeting to undertake an adaptation of the Medical eligibility criteria for contraceptive use (MEC) wheel. The main objectives of this process were to present technical updates of the various contraceptive methods, to update the current medical conditions prevalent to Botswana and to adapt the MEC wheel to meet the needs of the Botswanian people. This commentary focuses on the adaptation process that occurred during the week-long stakeholder workshop. It concludes with the key elements learned from this process that can potentially inform countries who are interested in undergoing a similar exercise to strengthen their family planning needs.

The role of the World Health Organization in male contraceptive development.

The World Health Organization has been involved in male contraceptive development for over 50 years. In line with its functions and mandate, World Health Organization works with diverse stakeholders to support research, develop norms and standards, engage member states, facilitate prequalification, introduction and scale up, measurement, and tracking of contraceptives. World Health Organization has a key role in galvanizing global efforts to ensure universal access to contraception services irrespective of income group. Regarding male contraceptive development, World Health Organization has provided technical leadership, supported early research, created and supported research centers, built research capacity in various countries, and standardized semen analysis procedures. In this paper, a detailed description is provided with examples across the various stages of male contraceptive development. Limited funding to World Health Organization is a key challenge.

It's not just about pads! Adolescent reproductive health views in Kenya: A qualitative secondary analysis.

Many adolescents face barriers to accessing reproductive health care even though quality reproductive health care is a fundamental human right. The objective of this study is to understand the requests of quality reproductive health among high school girls in Kenya. We conducted a secondary analysis of qualitative data from a sub-sample of adolescent girls in Kenya who participated in the What Women Want global campaign and analyzed interview data from key informants involved in the survey. We used pre-existing codes and current literature to design the coding framework and thematic analysis to describe emerging themes. Atlas. ti 8 was used to organize and analyze codes. Over 4,500 high school girls, ages 12 and 19 years, were included in the analysis, with 61.6% from all-girls boarding schools and 13.8% from mixed-day schools. Data from nine key informants complemented findings from the survey. Emerging themes included: 1) The need for improved menstrual health and hygiene: Sanitary towels and cleaner toilets; 2) Prevention of adolescent pregnancy: Access to contraception; 3) Respect and dignity: Participants want privacy and confidentiality; and 4) The need to address social determinants of health: Economic stability and a safe physical environment. This study indicated that adolescent high school girls have varied requests for reproductive health care and services. While menstrual health and hygiene are key issues, reproductive needs are beyond just sanitary products. The results suggest a need for targeted reproductive health interventions using a multi-sectoral approach.

In uncharted territory "together each achieves more": a United Nations interagency collaboration for continuity of maternal and newborn health services during the coronavirus pandemic in the Eastern and Southern Africa region.

The frangible collaboration between three United Nations agencies (UNICEF, UNFPA and WHO) in the Eastern and Southern Africa Region was strengthened by the outbreak of the coronavirus pandemic. The aim was to combine existing resources and expertise to support countries to respond to the pandemic more effectively and efficiently regarding the provision of maternal and newborn health services. Three kinds of activities were conducted: 15 webinars on a variety of topics and issues impacted by the pandemic; virtual training on maternal and perinatal death surveillance and response as well as on quality improvement; and the development of online e-learning modules for continuous professional development. Key dimensions of the collaboration included: a common vision; commitment to the process; dialogue; building relationships and trust; communication and information sharing; sharing of technical and financial resources and expertise; mobilization of additional resources; celebration of intermediate outcomes; facilitative leadership; and institutional design. Start-up lessons revolved around shared risk taking, while retaining agency autonomy. Collaboration lessons included forming a "united front", harnessing technology to accelerate results, and mitigating adverse structural and contextual factors. There are widespread perceptions that collaborative initiatives tend to yield minimum results in terms of increased efficiency or effectiveness. This particular collaborative effort demonstrated elements of feasibility, value addition, synergy, cost effectiveness and demonstrable results where UN agencies delivered as one. The emergency in healthcare as a ripple effect of the coronavirus pandemic has caused a rethink of collaboration models and levels of engagement.

Transitioning to Digital Systems: The Role of World Health Organization's Digital Adaptation Kits in Operationalizing Recommendations and Interoperability Standards.

INTRODUCTION: The transition from paper to digital systems requires quality assurance of the underlying content and application of data standards for interoperability. The World Health Organization (WHO) developed digital adaptation kits (DAKs) as an operational and software-neutral mechanism to translate WHO guidelines into a standardized format that can be more easily incorporated into digital systems. METHODS: WHO convened health program area and digital leads, reviewed existing approaches for requirements gathering, mapped to established standards, and incorporated research findings to define DAK components. RESULTS: For each health domain area, the DAKs distill WHO guidelines to specify the health interventions, personas, user scenarios, business process workflows, core data elements mapped to terminology codes, decision-support logic, program indicators, and functional and nonfunctional requirements. DISCUSSION: DAKs aim to catalyze quality of care and facilitate data use and interoperability as part of WHO's vision of SMART (Standards-based, Machine-readable, Adaptive, Requirements-based, and Testable) guidelines. Efforts will be needed to strengthen a collaborative approach for the uptake of DAKs within the local digital ecosystem and national health policies.

A Landscape Analysis of Offering HIV Testing Services Within Family Planning Service Delivery.

Introduction: Offering HIV testing services (HTS) within sexual and reproductive health (SRH) services is a priority, especially for women who have a substantial risk. To reach women with HIV who do not know their status and prevent mother-to-child HIV transmission, the World Health Organization (WHO) recommends routinely offering HTS as part of family planning (FP) service delivery in high HIV burden settings. We conducted a landscape analysis to assess HTS uptake and HIV positivity in the context of FP/SRH services. Assessment of Research and Programs: We searched records from PubMed, four gray literature databases, and 13 organization websites, and emailed 24 organizations for data on HTS in FP/SRH services. We also obtained data from International Planned Parenthood Federation (IPPF) affiliates in Eswatini, Kenya, Lesotho, Malawi, Namibia, Uganda, Zambia, and Zimbabwe. Unique programs/studies from records were included if they provided data on, or barriers/facilitators to, offering HTS in FP/SRH. Overall, 2,197 records were screened and 12 unique programs/studies were eligible, including 10 from sub-Saharan Africa. Four reported on co-delivery of SRH services (including FP), with reported HTS uptake between 17 and 94%. Six reported data on HTS in FP services: four among general FP clients; one among couples; and one among female sex workers, adolescent girls, and young women. Two of the six reported HTS uptake >50% (51%, 419/814 Kenya; 63%, 5,930/9,439 Uganda), with positivity rates of 2% and 4.1%, respectively. Uptake was low (8%, 74/969 Kenya) in the one FP program offering pre-exposure prophylaxis. In the IPPF program, seven countries reported HTS uptake in FP services and ranged from 4% in Eswatini to 90% in Lesotho; between 0.6% (Uganda) and 8% (Eswatini) of those tested were HIV positive. Implications: Data on providing HTS in FP/SRH service delivery were sparse and HTS uptake varied widely across programs. Actionable Recommendations: As countries expand HTS in FP/SRH appropriate to epidemiology, they should ensure data are reported and monitored for progress and impact.

Implementation of the new WHO antenatal care model for a positive pregnancy experience: a monitoring framework.

Monitoring the implementation and impact of routine antenatal care (ANC), as described in the new World Health Organization (WHO) ANC model, requires indicators that go beyond the previously used global benchmark indicator of four or more ANC visits. To enable consistent monitoring of ANC content and care processes and to provide guidance to countries and health facilities, WHO developed an ANC monitoring framework. This framework builds on a conceptual framework for quality ANC and a scoping review of ANC indicators that mapped existing indicators related to recommendations in the new WHO ANC model. Based on the scoping review and following an iterative and consultative process, we developed a monitoring framework consisting of core indicators recommended for monitoring ANC recommendations in all settings, as well as a menu of additional measures. Finally, a research agenda highlights areas where ANC recommendations exist, but measures require further development. Nine core indicators can already be monitored globally and/or nationally, depending on the preferred data sources. Two core indicators (experience of care, ultrasound scan before 24 weeks) are included as placeholders requiring priority by the research agenda. Six context-specific indicators are appropriate for national and subnational monitoring in various settings based on specific guidance. Thirty-five additional indicators may be relevant and desirable for monitoring, depending on programme priorities. Monitoring implementation of the new WHO ANC model and the outcomes of routine ANC require greater attention to the measurement of ANC content and care processes as well as women's experience of ANC.

Increased risk of HIV in women experiencing physical partner violence in Nairobi, Kenya.

As part of a study on etiology of sexually transmitted infections (STI) among 520 women presenting at the STI clinic in Nairobi, data on partner violence and its correlates were analyzed. Prevalence of lifetime physical violence was 26%, mainly by an intimate partner (74%). HIV seropositive women had an almost twofold increase in lifetime partner violence. Women with more risky sexual behavior such as early sexual debut, number of sex partners, history of condom use and of STI, experienced more partner violence. Parity and miscarriage were associated with a history of lifetime violence. We found an inverse association between schooling and level of violence. Six percent of the women had been raped. Gender-based violence screening and services should be integrated into voluntary counseling and testing programs as well as in reproductive health programs. Multi-sector approaches are needed to change prevailing attitudes towards violence against women.