Femicide, intimate partner femicide, and non-intimate partner femicide in South Africa: An analysis of 3 national surveys, 1999-2017.

BACKGROUND: In most countries, reliable national statistics on femicide, intimate partner femicide (IPF), and non-intimate partner femicide (NIPF) are not available. Surveys are required to collect robust data on this most extreme consequence of intimate partner violence (IPV). We analysed 3 national surveys to compare femicide, IPF, and NIPF from 1999 to 2017 using age-standardised rates (ASRs) and incidence rate ratios (IRRs). METHODS AND FINDINGS: We conducted 3 national mortuary-based retrospective surveys using weighted cluster designs from proportionate random samples of medicolegal laboratories. We included females 14 years and older who were identified as having been murdered in South Africa in 1999 (n = 3,793), 2009 (n = 2,363), and 2017 (n = 2,407). Further information on the murdered cases were collected from crime dockets during interviews with police investigating officers. Our findings show that South Africa had an IPF rate of 4.9/100,000 female population in 2017. All forms of femicide among women 14 years and older declined from 1999 to 2017. For IPF, the ASR was 9.5/100,000 in 1999. Between 1999 and 2009, the decline for NIPF was greater than for IPF (IRR for NIPF 0.47 (95% confidence interval (CI) 0.42 to 0.53) compared to IRR for IPF 0.69 (95% CI 0.63 to 0.77). Rates declined from 2009 to 2017 and did not differ by femicide type. The decline in IPF was initially larger for women aged 14 to 29, and after 2009, it was more pronounced for those aged 30 to 44 years. Study limitations include missing data from the police and having to use imputation to account for missing perpetrator data. CONCLUSIONS: In this study, we observed a reduction in femicide overall and different patterns of change in IPF compared to NIPF. The explanation for the reductions may be due to social and policy interventions aimed at reducing IPV overall, coupled with increased social and economic stability. Our study shows that gender-based violence is preventable even in high-prevalence settings, and evidence-based prevention efforts must be intensified globally. We also show the value of dedicated surveys in the absence of functional information systems.

Pathways to and factors associated with rape stigma experienced by rape survivors in South Africa: Analysis of baseline data from a rape cohort.

Rape stigma, both external and self-stigmatization (self-blame), is associated with adverse health outcomes. Understanding its origins and resilience factors is critical for reducing and preventing it. We describe the prevalence of rape stigma, the characteristics of women experiencing it and the pathways to experiencing greater stigma. The Rape Impact Cohort Evaluation study enrolled 852 women aged 16-40 years who had been raped from post-rape care centres in Durban, South Africa. We present a descriptive analysis of the baseline data, a multinomial logistic regression model of factors associated with different levels of stigma and a structural equation model (SEM). Most women reported stigmatizing thoughts or experiences, with self-stigmatizing thoughts being more prevalent than external stigmatization. The multinomial model showed that experiences of childhood or other trauma, emotional intimate partner violence (IPV), having less gender equitable attitudes and food insecurity were significantly associated with medium or high versus low levels of stigma. Internal and external stigma were significantly associated with each other. Women who had been previously raped reported less stigma. The SEM showed a direct path between food insecurity and rape stigma, with poorer women experiencing more stigma. Indirect paths were mediated by more traditional gender attitudes and childhood trauma experience and other trauma exposure. Our findings confirm the intersectionality of rape stigma, with its structural drivers of food insecurity and gender inequality, as well as its strong association with prior trauma exposure. Rape survivors may benefit from gender-empowering psychological support that addresses blame and shame.

In pursuit of intimacy: disability stigma, womanhood and intimate partnerships in South Africa.

Notions of womanhood inculcate naturalised ideologies of femininity, sexuality, motherhood and caregiving. The paper asks how disability stigma intersects with womanhood to characterise intimate partnerships in South Africa. In-depth interviews with 30 women with a range of disabilities were conducted in informal settlements in Cape Town. Findings suggest that disability stigma may hamper attainment of normative womanhood and sexual relationships for women with disabilities in South Africa. Limited opportunities to meet potential partners, hegemonic gender expectations and restricted sexual and physical contact shape their intimate partnerships. However, women with disabilities also challenge ableist constructs of normalcy and discredit negative images of disabled womanhood. Because of this, theoretical models of intimate partner violence should consider the influence of disability on constructions of sexuality and norms in intimate partnerships. Building on women with disabilities' stigma-avoidance strategies will help facilitate better relationship outcomes. Social norms interventions with broader society, communities, women with disabilities and their partners, family and carers can help destabilise assumptions that women with disabilities are unable to have long-lasting and fulfilling sexual and intimate partnerships. Moreover, accessible and relevant sexuality education and information on relationships, intimate partner violence, maternal and sexual and reproductive health care can ensure healthy and safe intimate partnerships for women with disabilities.

Violence against children in Latin America and the Caribbean: What do available data reveal about prevalence and perpetrators?

OBJECTIVE: To describe the prevalence of recent physical, sexual, and emotional violence against children 0 - 19 years of age in Latin America and the Caribbean (LAC) by age, sex, and perpetrator. METHODS: A systematic review and analysis of published literature and large international datasets was conducted. Eligible sources from first record to December 2015 contained age-, sex-, and perpetrator-specific data from LAC. Random effects meta-regressions were performed, adjusting for relevant quality covariates and differences in violence definitions. RESULTS: Seventy-two surveys (2 publications and 70 datasets) met inclusion criteria, representing 1 449 estimates from 34 countries. Prevalence of physical and emotional violence by caregivers ranged from 30% - 60%, and decreased with increasing age. Prevalence of physical violence by students (17% - 61%) declined with age, while emotional violence remained constant (60% - 92%). Prevalence of physical intimate partner violence (IPV) ranged from 13% - 18% for girls aged 15 - 19 years. Few or no eligible past-year estimates were available for any violence against children less than 9 years and boys 16 - 19 years of age; sexual violence against boys (any age) and girls (under 15 years); IPV except for girls aged 15 - 19 years; and violence by authority figures (e.g., teachers) or via gangs/organized crime. CONCLUSION: Past-year physical and emotional violence by caregivers and students is widespread in LAC across all ages in childhood, as is IPV against girls aged 15 - 19 years. Data collection must be expanded in LAC to monitor progress towards the sustainable development goals, develop effective prevention and response strategies, and shed light on violence relating to organized crime/gangs.

Intimate partner violence, forced first sex and adverse pregnancy outcomes in a sample of Zimbabwean women accessing maternal and child health care.

BACKGROUND: Intimate partner violence (IPV) remains a serious problem with a wide range of health consequences including poor maternal and newborn health outcomes. We assessed the relationship between IPV, forced first sex (FFS) and maternal and newborn health outcomes. METHODS: A cross sectional study was conducted with 2042 women aged 15-49 years attending postnatal care at six clinics in Harare, Zimbabwe, 2011. Women were interviewed on IPV while maternal and newborn health data were abstracted from clinic records. We conducted logistic regression models to assess the relationship between forced first sex (FFS), IPV (lifetime, in the last 12 months and during pregnancy) and maternal and newborn health outcomes. RESULTS: Of the recent pregnancies 27.6% were not planned, 50.9% booked (registered for antenatal care) late and 5.6% never booked. A history of miscarriage was reported by 11.5%, and newborn death by 9.4% of the 2042 women while 8.6% of recent livebirths were low birth weight (LBW) babies. High prevalence of emotional (63,9%, 40.3%, 43.8%), physical (37.3%, 21.3%, 15.8%) and sexual (51.7%, 35.6%, 38.8%) IPV ever, 12 months before and during pregnancy were reported respectively. 15.7% reported forced first sex (FFS). Each form of lifetime IPV (emotional, physical, sexual, physical/sexual) was associated with a history of miscarrying (aOR ranges: 1.26-1.38), newborn death (aOR ranges: 1.13-2.05), and any negative maternal and newborn health outcome in their lifetime (aOR ranges: 1.32-1.55). FFS was associated with a history of a negative outcome (newborn death, miscarriage, stillbirth) (aOR1.45 95%CI: 1.06-1.98). IPV in the last 12 months before pregnancy was associated with unplanned pregnancy (aOR ranges 1.31-2.02) and booking late for antenatal care. Sexual IPV (aOR 2.09 CI1.31-3.34) and sexual/physical IPV (aOR2.13, 95%CI: 1.32-3.42) were associated with never booking for antenatal care. Only emotional IPV during pregnancy was associated with low birth weight (aOR1.78 95%CI1.26-2.52) in the recent pregnancy and any recent pregnancy negative outcomes including LBW, premature baby, emergency caesarean section (aOR1.38,95%CI:1.03-1.83). CONCLUSIONS: Forced first sex (FFS) and intimate partner violence (IPV) are associated with adverse maternal and newborn health outcomes. Strengthening primary and secondary violence prevention is required to improve pregnancy-related outcomes.

Psychosocial group interventions to improve psychological well-being in adults living with HIV.

BACKGROUND: Being diagnosed with human immunodeficiency virus (HIV), and labelled with a chronic, life-threatening, and often stigmatizing disease, can impact on a person's well-being. Psychosocial group interventions aim to improve life-functioning and coping as individuals adjust to the diagnosis. OBJECTIVES: To examine the effectiveness of psychosocial group interventions for improving the psychological well-being of adults living with HIV/AIDS. SEARCH METHODS: We searched the following electronic databases up to 14 March 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) published in the Cochrane Library (Issue 2, 2016), PubMed (MEDLINE) (1996 to 14 March 2016), Embase (1996 to 14 March 2016), and Clinical Trials.gov. SELECTION CRITERIA: Randomized controlled trials (RCTs) or quasi-RCTs that compared psychosocial group interventions with versus control (standard care or brief educational interventions), with at least three months follow-up post-intervention. We included trials that reported measures of depression, anxiety, stress, or coping using standardized scales. DATA COLLECTION AND ANALYSIS: Two review authors independently screened abstracts, applied the inclusion criteria, and extracted data. We compared continuous outcomes using mean differences (MD) with 95% confidence intervals (95% CIs), and pooled data using a random-effects model. When the included trials used different measurement scales, we pooled data using standardized mean difference (SMD) values. We reported trials that we could not include in the meta analysis narratively in the text. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included 16 trials (19 articles) that enrolled 2520 adults living with HIV. All the interventions were multifaceted and included a mix of psychotherapy, relaxation, group support, and education. The included trials were conducted in the USA (12 trials), Canada (one trial), Switzerland (one trial), Uganda (one trial), and South Africa (one trial), and published between 1996 and 2016. Ten trials recruited men and women, four trials recruited homosexual men, and two trials recruited women only. Interventions were conducted with groups of four to 15 people, for 90 to 135 minutes, every week for up to 12 weeks. All interventions were conducted face-to-face except two, which were delivered by telephone. All were delivered by graduate or postgraduate trained health, psychology, or social care professionals except one that used a lay community health worker and two that used trained mindfulness practitioners.Group-based psychosocial interventions based on cognitive behavioural therapy (CBT) may have a small effect on measures of depression, and this effect may last for up to 15 months after participation in the group sessions (SMD -0.26, 95% CI -0.42 to -0.10; 1139 participants, 10 trials, low certainty evidence). Most trials used the Beck Depression Inventory (BDI), which has a maximum score of 63, and the mean score in the intervention groups was around 1.4 points lower at the end of follow-up. This small benefit was consistent across five trials where participants had a mean depression score in the normal range at baseline, but trials where the mean score was in the depression range at baseline effects were less consistent. Fewer trials reported measures of anxiety, where there may be little or no effect (four trials, 471 participants, low certainty evidence), stress, where there may be little or no effect (five trials, 507 participants, low certainty evidence), and coping (five trials, 697 participants, low certainty evidence).Group-based interventions based on mindfulness have not demonstrated effects on measures of depression (SMD -0.23, 95% CI -0.49 to 0.03; 233 participants, 2 trials, very low certainty evidence), anxiety (SMD -0.16, 95% CI -0.47 to 0.15; 62 participants, 2 trials, very low certainty evidence), or stress (MD -2.02, 95% CI -4.23 to 0.19; 137 participants, 2 trials, very low certainty evidence). No mindfulness based interventions included in the studies had any valid measurements of coping. AUTHORS' CONCLUSIONS: Group-based psychosocial interventions may have a small effect on measures of depression, but the clinical importance of this is unclear. More high quality evidence is needed to assess whether group psychosocial intervention improve psychological well-being in HIV positive adults.

Gender Differences in Homicide of Neonates, Infants, and Children under 5 y in South Africa: Results from the Cross-Sectional 2009 National Child Homicide Study.

BACKGROUND: Homicide of children is a global problem. The under-5-y age group is the second largest homicide age group after 15-19 y olds, but has received little research attention. Understanding age and gender patterns is important for assisting with developing prevention interventions. Here we present an age and gender analysis of homicides among children under 5 y in South Africa from a national study that included a focus on neonaticide and infanticide. METHODS AND FINDINGS: A retrospective national cross-sectional study was conducted using a random sample of 38 medico-legal laboratories operating in 2009 to identify homicides of children under 5 y. Child data were abstracted from the mortuary files and autopsy reports, and both child and perpetrator data data were collected from police interviews. We erred towards applying a conservative definition of homicide and excluded sudden infant death syndrome cases. We estimated that 454 (95% CI 366, 541) children under the age of 5 y were killed in South Africa in 2009. More than half (53.2%; 95% CI 46.7%, 59.5%) were neonates (0-28 d), and 74.4% (95% CI 69.3%, 78.9%) were infants (under 1 y), giving a neonaticide rate of 19.6 per 100,000 live births and an infanticide rate of 28.4 per 100,000 live births. The majority of the neonates died in the early neonatal period (0-6 d), and abandonment accounted for 84.9% (95% CI 81.5%, 87.8%) of all the neonates killed. Distinct age and gender patterns were found, with significantly fewer boy children killed in rural settings compared to urban settings (odds ratio 0.6; 95% CI 0.4, 0.9; p = 0.015). Abuse-related killings and evidence of sexual assault were more common among older girls than in all other age and gender groups. Mothers were identified as the perpetrators in all of the neonaticides and were the most common perpetrators overall (71.0%; 95% CI 63.9%, 77.2%). Abandoned neonates were mainly term babies, with a mean gestational age of 38 wk. We did not have information on abandonment motives for all newborns and did not know if babies were abandoned with the intention that they would die or with the hope that they would be found alive. We therefore considered all abandoned babies as homicides. CONCLUSIONS: Homicide of children is an extreme form or consequence of violence against children. This national study provides one of the first analyses of neonaticide and infanticide by age and gender and shows the failure of reproductive and mental health and social services to identify and help vulnerable mothers. Multi-sectoral prevention strategies are needed.

Addressing violence against women: a call to action.

Violence against women and girls is prevalent worldwide but historically has been overlooked and condoned. Growing international recognition of these violations creates opportunities for elimination, although solutions will not be quick or easy. Governments need to address the political, social, and economic structures that subordinate women, and implement national plans and make budget commitments to invest in actions by multiple sectors to prevent and respond to abuse. Emphasis on prevention is crucial. Community and group interventions involving women and men can shift discriminatory social norms to reduce the risk of violence. Education and empowerment of women are fundamental. Health workers should be trained to identify and support survivors and strategies to address violence should be integrated into services for child health, maternal, sexual, and reproductive health, mental health, HIV, and alcohol or substance abuse. Research to learn how to respond to violence must be strengthened. The elimination of violence against women and girls is central to equitable and sustainable social and economic development and must be prioritised in the agenda for development after 2015.

A Psychosocial Understanding of Child Sexual Abuse Disclosure Among Female Children in South Africa.

Child sexual abuse is endemic in South Africa, driven by high levels of gender-based violence and underscored by structural and social factors. This article aims to develop an understanding of the process of disclosure in a sample of female children and their caregivers. In-depth semistructured interviews were conducted with 31 female children aged 8-17 years and their caregivers at 3 intervals after presentation to a sexual assault treatment center. Nearly half of the children failed to disclose the sexual abuse immediately, fearing caregivers' reaction. Most children purposefully disclosed to a confidant through a process of identifying an intermediary to tell caregivers on their behalf. The process of disclosure was influenced by multiple factors, such as a fear of the caregiver's reaction and disbelief, which is related to parental style. Disclosure was found to be a dynamic process that unfolds and not a single or static event and influenced by multiple factors which all impact on recovery. Our findings highlight the need to address social norms on sexual abuse in order to improve responses to disclosure to facilitate post-sexual-abuse adjustment for the child and the family.

Worldwide prevalence of non-partner sexual violence: a systematic review.

BACKGROUND: Several highly publicised rapes and murders of young women in India and South Africa have focused international attention on sexual violence. These cases are extremes of the wider phenomenon of sexual violence against women, but the true extent is poorly quantified. We did a systematic review to estimate prevalence. METHODS: We searched for articles published from Jan 1, 1998, to Dec 31, 2011, and manually search reference lists and contacted experts to identify population-based data on the prevalence of women's reported experiences of sexual violence from age 15 years onwards, by anyone except intimate partners. We used random effects meta-regression to calculate adjusted and unadjusted prevalence for regions, which we weighted by population size to calculate the worldwide estimate. FINDINGS: We identified 7231 studies from which we obtained 412 estimates covering 56 countries. In 2010 7.2% (95% CI 5.2-9.1) of women worldwide had ever experienced non-partner sexual violence. The highest estimates were in sub-Saharan Africa, central (21%, 95% CI 4.5-37.5) and sub-Saharan Africa, southern (17.4%, 11.4-23.3). The lowest prevalence was for Asia, south (3.3%, 0-8.3). Limited data were available from sub-Saharan Africa, central, North Africa/Middle East, Europe, eastern, and Asia Pacific, high income. INTERPRETATION: Sexual violence against women is common worldwide, with endemic levels seen in some areas, although large variations between settings need to be interpreted with caution because of differences in data availability and levels of disclosure. Nevertheless, our findings indicate a pressing health and human rights concern. FUNDING: South African Medical Research Council, Sigrid Rausing Trust, WHO.

Injury-related mortality in South Africa: a retrospective descriptive study of postmortem investigations.

OBJECTIVE: To investigate injury-related mortality in South Africa using a nationally representative sample and compare the results with previous estimates. METHODS: We conducted a retrospective descriptive study of medico-legal postmortem investigation data from mortuaries using a multistage random sample, stratified by urban and non-urban areas and mortuary size. We calculated age-specific and age-standardized mortality rates for external causes of death. FINDINGS: Postmortem reports revealed 52,493 injury-related deaths in 2009 (95% confidence interval, CI: 46,930-58,057). Almost half (25,499) were intentionally inflicted. Age-standardized mortality rates per 100,000 population were as follows: all injuries: 109.0 (95% CI: 97.1-121.0); homicide 38.4 (95% CI: 33.8-43.0; suicide 13.4 (95% CI: 11.6-15.2) and road-traffic injury 36.1 (95% CI: 30.9-41.3). Using postmortem reports, we found more than three times as many deaths from homicide and road-traffic injury than had been recorded by vital registration for this period. The homicide rate was similar to the estimate for South Africa from a global analysis, but road-traffic and suicide rates were almost fourfold higher. CONCLUSION: This is the first nationally representative sample of injury-related mortality in South Africa. It provides more accurate estimates and cause-specific profiles that are not available from other sources.

The global prevalence of intimate partner homicide: a systematic review.

BACKGROUND: Homicide is an important cause of premature mortality globally, but evidence for the magnitude of homicides by intimate partners is scarce and hampered by the large amount of missing information about the victim-offender relationship. The objective of the study was to estimate global and regional prevalence of intimate partner homicide. METHODS: A systematic search of five databases (Medline, Global Health, Embase, Social Policy, and Web of Science) yielded 2167 abstracts, and resulted in the inclusion of 118 full-text articles with 1122 estimates of the prevalence of intimate partner homicide after double-blind screening. All studies were included that reported the number or proportion of women or men who were murdered by an intimate partner in a country, province, or town, using an inclusive definition of an intimate partner. Additionally, a survey of official sources of 169 countries provided a further 53 estimates. We selected one estimate per country-year using a quality assessment decision algorithm. The median prevalence of intimate partner homicide was calculated by country and region overall, and for women and men separately. FINDINGS: Data were obtained for 66 countries. Overall 13·5% (IQR 9·2-18·2) of homicides were committed by an intimate partner, and this proportion was six times higher for female homicides than for male homicides (38·6%, 30·8-45·3, vs 6·3%, 3·1-6·3). Median percentages for all (male and female) and female intimate partner homicide were highest in high-income countries (all, 14·9%, 9·2-18·2; female homicide, 41·2%, 30·8-44·5) and in southeast Asia (18·8%, 11·3-18·8; 58·8%, 58·8-58·8). Adjustments to account for unknown victim-offender relationships generally increased the prevalence, suggesting that results presented are conservative. INTERPRETATION: At least one in seven homicides globally and more than a third of female homicides are perpetrated by an intimate partner. Such violence commonly represents the culmination of a long history of abuse. Strategies to reduce homicide risk include increased investment in intimate partner violence prevention, risk assessments at different points of care, support for women experiencing intimate partner violence, and control of gun ownership for people with a history of violence. Improvements in country-level data collection and monitoring systems are also essential, because data availability and quality varied strongly across regions. FUNDING: WHO, Sigrid Rausing Trust, and the UK Economic and Social Research Council.

Who is killing South African men? A retrospective descriptive study of forensic and police investigations into male homicide.

Not much is known about the perpetrators of male homicide in South Africa, which has rates seven times the global average. For the country's first ever male homicide study we describe the epidemiology of perpetrators, their relationship with victims and victim profiles of men killed by male versus female perpetrators. We conducted a retrospective descriptive study of routine data collected through forensic and police investigations, calculating victim and perpetrator homicide rates by age, sex, race, external cause, employment status and setting, stratified by victim-perpetrator relationships. For perpetrators, we reported suspected drug and alcohol use, prior convictions, gang-involvement and homicide by multiple perpetrators. Perpetrators were acquaintances in 63% of 5594 cases in which a main perpetrator was identified. Sharp objects followed by guns were the main external causes of death. The highest rates were recorded in urban informal areas among unemployed men across all victim-perpetrator relationship types. Recreational settings including bars featured prominently. Homicides clustered around festive periods and weekends, both of which are associated with heavy episodic drinking. Perpetrator alcohol use was reported in 41% of homicides by family members and 50% by acquaintances. Other drug use was less common (9% overall). Of 379 men killed by female perpetrators, 60% were killed by intimate partners. Perpetrator alcohol use was reported in approximately half of female-on-male murders. Female firearm use was exclusively against intimate partners. No men were killed by male intimate partners. Violence prevention, which in South Africa has mainly focused on women and children, needs to be integrated into an inclusive approach. Profiling victims and perpetrators of male homicide is an important and necessary first step to challenge prevailing masculine social constructs that men are neither vulnerable to, nor the victims of, trauma and to identify groups at risk of victimisation that could benefit from specific interventions and policies.

Child abuse and neglect-related murders in South Africa: a comparison of two national surveys in 2009 and 2017.

BACKGROUND: Population-based statistics on deaths from child abuse and neglect are only routinely available in countries that have reliable national statistics on child murder. For low-income and middle-income countries, relatively little is known about prevalence trends of child murder. South Africa is an exception, having conducted dedicated national studies on child murders for 2009 and 2017 to provide data on child murders overall and on child abuse and neglect-related murders. We aimed to compare child abuse and neglect-related murders in South Africa across two surveys to determine any change between 2009 and 2017. METHODS: We conducted two retrospective national mortuary-based surveys on murder of children aged 0-17 years for 2009 and 2017 from a proportionate random sample of medico-legal laboratories in South Africa. A sampling frame of medico-legal laboratories for each study year was prepared with stratification by medico-legal laboratory size. A minimum of 2 years after the crime was allowed before data collection to enable progression of the investigation process. Child abuse and neglect-related murders were identified using both medico-legal laboratory post-mortem autopsy reports and police data. To identify a child abuse and neglect-related murder, we primarily used the framework of abuse happening within the context of responsibility of care arrangements but broadened this to include all perpetrators and abuse identified from the data. We stratified age into 0-4, 5-9, 10-14, and 15-17 years and further stratified children younger than 5 years into early neonates (newborns killed within 6 days of birth), 7 days to 11 months, and 1-4 years. We calculated incidence rate ratios (IRR) with 95% CIs to compare rates between 2009 and 2017. FINDINGS: An estimated 458 (95% CI 377-539) children in 2009 and 213 (179-247) children in 2017 were murdered in circumstances of child abuse and neglect. The percentage of all child murders that were child abuse and neglect-related declined from 2009 to 2017 (458 [45·0%] of 1018 in 2009 vs 213 [25·0%] of 851 in 2017), with the overall age-standardised rate decreasing from 2·6 to 1·1 per 100 000 children aged 0-17 years (IRR 0·43 [95% CI 0·35-0·54]). Girls represented 276 (60·3%) of 458 murders in 2009, which declined to 96 (45·1%) of 213 murders in 2017, and boys represented 178 (38·9%) of 458 murders in 2009 and 109 (51·4%) of 213 murders in 2017. The decrease was statistically significant for girls in the 0-4 year (IRR 0·33 [0·22-0·49]) and 5-9 year (0·33 [0·15-0·73]) age groups and for boys in the 0-4 year age group (0·49 [0·33-0·71]). Among early neonates (within 6 days of birth), the decrease in child abuse and neglect-related murders was more pronounced among girls than among boys (IRR 0·33 [95% CI 0·19-0·56] vs 0·46 [0·28-0·77]). INTERPRETATION: Child abuse and neglect-related murders are common in South Africa but our study shows that they can be reduced. The high rate of these murders points to the need to continue research and monitoring to inform priority targeted interventions and to better understand the impact of child support policies. FUNDING: Ford Foundation and South African Medical Research Council.

Injury mortality in South Africa: a 2009 and 2017 comparison to track progress to meeting sustainable development goal targets.

BACKGROUND: Injuries, often preventable, prompted urgent action within the United Nations' 2030 Agenda for Sustainable Development Goals (SDGs) to improve global health. South Africa (SA) has high rates of injury mortality, but accurate reporting of official national data is hindered by death misclassification. OBJECTIVE: Two nationally representative surveys for 2009 and 2017 are utilised to assess SA's progress towards SDG targets for violence and road traffic injuries, alongside changes in suicide and under-5 mortality rates for childhood injuries, and compare these estimates with those of the Global Burden of Disease for SA. METHODS: The surveys utilised multi-stage, stratified cluster sampling from eight provinces, with mortuaries as primary sampling units. Post-mortem files for non-natural deaths were reviewed, with additional data from the Western Cape. Age-standardised rates, 95% confidence intervals (CIs), and incidence rate ratios (IRRs) were calculated for manner of death rate comparisons and for age groups. RESULTS: The all-injury age-standardised mortality rate decreased significantly between 2009 and 2017. Homicide and transport remained the leading causes of injury deaths, with a significant 31% decrease in road traffic mortality (IRR = 0.69), from 36.1 to 25.0 per 100 000 population. CONCLUSIONS: Despite a reduction in SA's road traffic mortality rate, challenges to achieve targets related to young and novice drivers and male homicide persist. Achieving SA's injury mortality SDG targets requires comprehensive evaluations of programmes addressing road safety, violence reduction, and mental well-being. In the absence of reliable routine data, survey data allow to accurately assess the country's SDG progress through commitment to evidence-based policymaking.

Main findings The significant decrease in South Africa's injury mortality rates between 2009 and 2017 appears to largely be driven by the significant 31% decrease in road traffic mortality rates.Added knowledge The 2009 and 2017 survey comparison provides an enhanced understanding of the profile for injury-related deaths, compared to misclassified vital statistics data, to track progress towards reaching Sustainable Development Goals.Global health impact for policy and action The significant reduction in road traffic mortality across all age groups suggests South Africa is making progress towards Sustainable Development Goal Target 3.6 for road safety. However, reducing violence, suicide, and newborn and under-5 injury mortality requires more targeted interventions.

Intimate partner femicide in South Africa in 1999 and 2009.

BACKGROUND: Death is the most extreme consequence of intimate partner violence. Female homicide studies with data on the perpetrator-victim relationship can provide insights. We compare the results of two South African national studies of female homicide with similar sampling done 10 y apart. METHODS AND FINDINGS: We conducted a retrospective national survey using a weighted cluster design of a proportionate random sample of 38 mortuaries to identify homicides committed in 2009. We abstracted victim data from mortuary and autopsy reports, and perpetrator data from police interviews. We compared homicides of women 14 y and older in 2009 with previously published data collected with the same methodology for homicides committed in 1999. The study found that the rate of female homicide per 100,000 female population in 2009 was 12.9 (95% confidence interval [CI]: 9.3, 16.5), compared to 24.7 (95% CI: 17.7, 31.6) in 1999. The incidence rate ratio of 0.54 (95% CI: 0.20, 0.84) reflects a significantly lower rate in 2009. The rate of intimate partner femicide was 5.6/100,000 in 2009 versus 8.8/100,000 in 1999, with an incidence rate ratio of 0.63 (95% CI: 0.24, 1.02), indicating no difference between rates. Logistic regression analysis of homicide characteristics showed that the odds ratio of suspected rape among non-intimate femicides in 2009 compared to 1999 was 2.61 (95% CI: 1.23, 4.08) and among intimate partner femicides it was 0.84 (95% CI: 0.50, 1.42). The OR of homicide by gunshot was 0.54 (95% CI: 0.30, 0.99) in 2009 versus 1999. There was a significant drop in convictions of perpetrators of non-intimate femicide in 2009 versus 1999 (OR = 0.32 [95% CI: 0.19, 0.53]). Limitations of the study include the relatively small sample size and having only two time points. CONCLUSIONS: Female homicide in South Africa was lower in 2009 than 1999, but intimate partner femicide and suspected rape homicide rates were not statistically different. The cause of the difference is unknown. The findings suggest that South Africa needs greater efforts nationally to implement evidence-based violence prevention. Please see later in the article for the Editors' Summary.

The epidemiology of child homicides in South Africa.

OBJECTIVE: To describe age- and sex-specific rates of child homicide in South Africa. METHODS: A cross-sectional mortuary-based study was conducted in a national sample of 38 medicolegal laboratories operating in 2009. These were sampled in inverse proportion to the number that were operational in each of three strata defined by autopsy volume: < 500, 500-1499 or > 1499 annual autopsies. Child homicide data were collected from mortuary files, autopsy reports and police interviews. Cause of death, evidence of abuse and neglect or of sexual assault, perpetrator characteristics and circumstances surrounding the death were investigated. FINDINGS: An estimated 1018 (95% confidence interval, CI: 843-1187) child homicides occurred in 2009, for a rate of 5.5 (95% CI: 4.6-6.4) homicides per 100 000 children younger than 18 years. The homicide rate was much higher in boys (6.9 per 100 000; 95% CI: 5.6-8.3) than in girls (3.9 per 100 000; 95% CI: 3.2-4.7). Child abuse and neglect had preceded nearly half (44.5%) of all homicides, but three times more often among girls than among boys. In children aged 15 to 17 years, the homicide rate among boys (21.7 per 100 000; 95% CI: 14.2-29.2) was nearly five times higher than the homicide rate among girls (4.6 per 100 000; 95% CI: 2.4-6.8). CONCLUSION: South Africa's child homicide rate is more than twice the global estimate. Since a background of child abuse and neglect is common, improvement of parenting skills should be part of primary prevention efforts.

Opportunities and obstacles to screening pregnant women for intimate partner violence during antenatal care in Zimbabwe.

Pregnancy offers an opportunity for midwives to recognise and respond to women experiencing intimate partner violence (IPV). However, most antenatal care interventions have been conducted in private specialist services in high-income countries and do not address the structural and cultural realities of developing country settings. We report on an exploratory qualitative study conducted in antenatal public health facilities in Harare, Zimbabwe, involving six in-depth interviews with midwives and seven FGDs with 64 pregnant and postpartum women. Recorded interviews were transcribed verbatim and analysed using thematic content analysis. We found that identifying and responding to IPV in antenatal care is hampered by inadequate human, financial and infrastructural resources as well as poor support of gender-based violence training for midwives. Midwives had divergent views of their role, with some perceiving IPV as a non-clinical, social and domestic problem that does not require their attention, while others who had been sensitised to the problem felt that it could easily overwhelm them. A comprehensive response to IPV by midwives would be difficult to achieve in this setting but sensitised midwives could respond to cues to violence and ultimately assist abused women in culturally sensitive and appropriate ways.

Exploring mental health adjustment of children post sexual assault in South Africa.

Large numbers of children are affected by child sexual abuse in South Africa. This study aimed to assess psychological adjustment of children post sexual assault. In-depth, semistructured interviews were conducted with caretakers, and structured interviews using mental health assessment screening tools were given to children at three intervals over a five-month period after presentation at a sexual assault center. Almost half of the children met clinical criteria for anxiety, and two-thirds met criteria for full symptom post-traumatic stress disorder two to four weeks post disclosure. With standard care, we observed some recovery; 43.3% of children still met full symptom post-traumatic stress disorder nearly six months post disclosure. Our findings indicate that current practice in South Africa does not promote adequate recovery for children.