Preparing for the Worst - Promoting Safety Behaviours in Antenatal Care Among Norwegian, Pakistani and Somali Pregnant Women
Phase: NA
Conditions: Intimate Partner Violence
Sponsor: Oslo Metropolitan University

 
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Preparing for the worst – promoting safety 
behaviours in antenatal care among Norwegian, 
Pakistani and Somali pregnant women. A 
randomised controlled trial 
 
Protocol  
 
29th December 2017 
 
1. Relevance relative to the call for proposal 
Our project answers to the call for intervention projects. We will develop an intervention to promote 
safety behaviours among pregnant women suffering violence. For too long, pregnant women’s 
needs, when living in an unsafe environment, have been overlooked. More women die at the hand 
of their partner/former partner, than from pregnancy and birth related complications in Norway 
(www.politi.no/kripos/statistikk/drap) (1). Intimate partner violence (IPV) is a risk for numerous 
adverse outcomes of pregnancy (2-4). Little is known as to how to assess and intervene and hence 
potentially prevent adverse outcomes for mother and child (5). Although IPV occurs in all social 
strata, women with low education, women with limited economic resources and women with 
subordinated positions compared to men are at higher risk (6). Immigrant women are likely to be 
overrepresented in these groups; hence they are more prone to be exposed to IPV (6). In Norwegian 
crisis shelters, immigrant women are overrepresented (7).  
In Norway, midwives and family doctors within the community provide most of the 
antenatal care. Almost all pregnant women attend these services. This provides a unique 
opportunity for community health workers to identify women at risk and provide them with the help 
they need. New guidelines in Norway instruct health professionals to routinely ask all pregnant 
women about their experience of violence (8). Enquiring and responding appropriately is not an 
easy task for community midwives and family doctors.  
Our project aims at assisting midwives and doctors in the community to ask about violence, 
through providing them with additional education about violence and ensuring they have 
established contact with other first line community services such as social workers, legal advisors, 
crisis centres and the police. In order to accomplish this, we will organise meetings and short 
courses. We will, in collaboration with women who have been pregnant and have suffered violence 
as well as health workers, adapt a screening tool for violence for women who read and speak 
Norwegian, English, Urdu and Somali. In addition, will we develop a video that promotes culturally 
adapted safety behaviours for the three language groups, involving both users and providers of the 
services as well as experts in the field, for example professionals from the crisis centres. Our 
intervention of staff training, a screening tool, and a safety promoting video aims to reduce violence 
and its consequences. Including not only Norwegian women but also those with an immigrant 
background contributes to reducing social differences in healthcare.  
 
2. Background and status of knowledge 
In 2014, a political decision to ask all pregnant women about prior or on going exposure to violence 
during antenatal care was made in Norway (8). It is the community midwives and family doctors 
that initially meet pregnant women thus are responsible to ask about violence. It is suggested that a 
simple assessment for violence and offering of referrals has the potential to interrupt and prevent 
recurrence of IPV (9) and that teaching victims relevant ways of promoting their safety has the 
potential to reduce IPV and associated trauma (10). Despite guidelines on how to examine exposure 

 
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to violence, studies have shown that it is difficult to implement questions about violence in clinical 
practise (11, 12). There is also little evidence that supports effective interventions (13) and this 
project aim to address this knowledge gap. 
 
What and how big is the problem? 
Violence against women is a phenomenon that persists in all countries (14). It encompasses a range 
of different form of violence like female genital mutilation, honour killings, IPV and sexual abuse 
(14, 15). A focus on women does not deny violence against men. In 1996, violence was declared as 
major public health problem (15). However, women are usually exposed to the most severe and 
long lasting violence (15) and the perpetrators are often current or former intimate partners. 
WHO state that 30 % of women worldwide have been exposed to physical and/ or sexual 
violence by intimate partner sometimes during life (2). In a Norwegian prevalence study from 2014, 
14.4% of the participating women reported less severe physical violence and 8.2% had been 
exposed to severe physical violence from an intimate partner/ex-partner (16). A pregnancy does not 
protect women from violence and the prevalence indicates that clinicians will meet women that are 
or have been exposed to IPV. Only one pilot project has asked about violence during antenatal care 
in Norway (11). Among 451 women 1.8% were exposed to violence during the pregnancy (11). In 
other studies that have asked pregnant women regarding violence, between 3-5% have been 
exposed during the last 12 months (17-19). The Norwegian studies were not facilitated for minority 
populations hence a knowledge gap regarding IPV in different immigrant groups exists (11, 16).  
In this project, a holistic approach is used to understand IPV, were the interaction between 
structural, relational and individual factors is taken into consideration. This understanding, initially 
based on Bronfenbrenner’s ecological model and adapted by WHO (15), will be used as a 
conceptual framework when exploring IPV. In addition, we will use the Transtheoretical model of 
change (20). Implementing change among patients and in a system is challenging and this model is 
adapted to the special case of intimate partner violence (20).  
Known risk factors for violence against women are being young, single, drug and alcohol 
consumption, low economic status and a former history of abuse (6, 15). There is an agreement that 
gender power inequalities and hierarchical gender relations in societies increase violence, both the 
violence that takes place within families, marriage, dating relations and the non-partner violence 
(6).Although immigrant women are a heterogeneous group, factors related to their migration 
context may make them more vulnerable to IPV. This can be economic insecurity, language 
barriers, family separation, social isolating and discrimination (21). Intimate partner violence has 
personal, within family and socio-economical consequences (2, 15, 22):  
 
Personal effect – women and children 
 
Death and injury 
 
Disease and ill-health, mental illness 
 
Substance abuse 
 
Poor social functioning, social isolation 
 
Lost productivity  
 
Poor school performance 
 
Increased risk in performing violence as adults  
Within families  
 
Children living with violence 
 
Inability to work 
 
Lost wages and productivity 
 
Housing instability 
Socio-economical effects 
 
Cost of services provided to those exposed to violence  
 
Lost of productivity  
 
Perpetuation of violence 
 
Violence in pregnancy is associated with reproductive coercion, unintended/rapid repeat pregnancy, 
poor maternal weight gain, hyper-emesis, antenatal hospitalizations, miscarriage, bleeding, mode of 
delivery, preterm birth and maternal mental health problems (23). IPV has a significant impact in 
women’s parenting abilities that can compromise their children’s development (24). 
 
Immigrant women in Norway 
Table 1: Overview of possible consequences 

 
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Since the 1960’s, there has been a rapid increase in the immigrant population in Norway (25). 
Today, immigrants and those born in Norway to immigrant parents constitute 15,6% of the total 
population. The five largest groups are from: Poland, Lithuania, Sweden, Somalia and Pakistan 
(www.ssb.no). A large number of immigrant women are in their childbearing years. In 2012 
immigrant women contributed to 23% of the births in Norway (26). Somali women have the highest 
fertility rate with 3,9 children pr. woman (26). Some reproductive challenges are identified in 
different immigrant groups, such as increased risk of hyper-emesis, induction of labor, fetal distress, 
operative deliveries, preterm birth, small for gestational age babies and prenatal death (27-29).  
 
Screening for violence during pregnancy  
The Norwegian governments decision about asking pregnant women about violence during 
antenatal care (8) is supported by guidelines from the UK (30). Antenatal care is recognised as an 
ideal “window of opportunity” to address IPV because this is a time when women are in regular 
contact with heath care providers (31). Pregnancy is an important context for safety planning as 
child well-being and safety is a priority for many abused women (32). Women may also be 
motivated for change. Today, no standard instrument for screening exists. The new guidelines 
suggests some questions and they that clinicians talk about strategies to prevent violence with 
women that disclose violence (8). Barriers for implementation are the sensitive topic, lack of 
training and uncertainty about management after disclosure (33). A Norwegian study shows that the 
majority of midwives were positive to ask when properly trained (11).  
The main recommended interventions for IPV in primary care settings involves questions 
about violence, information of safety-promoting behaviours, and referral to community resources 
(33, 34). Safety-promoting education includes a process that informs and empowers abused women 
by identifying behaviours they can adopt to increase safety and decrease exposure to violence (35). 
This is described as a helpful and preferred strategy among abused women to reduce violence (10, 
36). Different safety-promoting behaviours include use of informal and formal network, legal aid, 
resistance and placating (37). Examples of concrete safety actions may include hiding money or 
establish a code with family and friends to ensure help when violence occurs. The safety behaviours 
promoted in our video will be based on the Safety behaviour checklist (10). We will include 
previous victims of abuse from all three groups in addition to experts to adapt the safety behaviours 
to the Norwegian setting for women from different cultural backgrounds in a digital format.  
 
Relevance for patience care  
In summary, there is a strong rationale for developing and testing an intervention that help women 
increase their use of safety behaviours. Promoting safety behaviours may empower women and help 
them to take appropriate actions to ensure safety and well-being for themselves and their children 
and in the long term prevent harm. Developing and testing a tailored tool to reduce IPV is highly 
relevant and may give large benefits for the individual women and to the society at large. This 
project also aims to cover a knowledge gap regarding violence among minority groups (22, 38), and 
the project will ensure the participation of two large groups, Pakistani and Somali women, to gain 
further knowledge of IPV. Because of challenges in implementing questions about violence as a 
clinical practise (39, 40), both the screening/intervention and the professional development for 
midwives are planned as helpful actions for implementation. The screening and intervention are 
planned as accessible tools and if shown to be effective, they can easily be implemented in antenatal 
care in all of Norway. 
 
Aim, hypotheses and methods  
The overall main aim of the study is to reduce intimate partner violence through an intervention 
during pregnancy. We hypothesize that women who are randomized to an intervention that includes 
education about safety behaviours will use these behaviours and ultimately be less exposed to 
violence compared with women randomized to standard care. Their experience of the interventions 
and the experience of the community health staff will be assessed by qualitative interviews. 
 
The objectives of this study are to:  

 
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1. Develop a screening tool for violence and intervention to increase safety behaviours, culturally 
and linguistically adapted to Norwegian, Somali & Pakistani women (WP1). 
2. Increase the knowledge on IPV and skills in enquiring and caring for women in antenatal care. 
Educate health staff in the use of a screening tool for violence and safety instrument (WP2)  
3. Assess the level of IPV during pregnancy before and after intervention among Norwegian, 
Pakistani and Somali women (WP3).  
4. Assess the effect of the intervention through a randomized controlled trial (RCT) (WP3). 
5. Evaluate midwives experience of the study with the tablet technology (WP4). 
6. To explore women’s (users) experience of the intervention (WP4). 
 
The “Preparing for the worst” studyis planned as a randomised trial in antenatal care to test the 
effectives of a tablet-based intervention that promotes safety behaviour and it will include four work 
packages:  
 
Work packages 
 
 
 
 
 
 
Work package 1: Develop the screening tool and safety-promoting video 
Using tablet technology is a new and original approach in antenatal care. The screening tool for IPV 
and other questions for the baseline data collection will be developed for use on the tablet. The 
tablets allow uniformity of the data-collection so comparison within and between the groups can be 
done. Appropriate language will be ensured (Norwegian, English, Urdu, Somali). The final 
screening and will be carried out using tablet technology and Audio Computer Assisted Self 
Interviews (ACASI). A-CASI tend to yield higher rates of IPV disclosure (41). 
The safety-promoting video which women randomized to this option will view right after 
the A-CASI, will consist of digital storytelling: combining narrative with digital content, including 
images, sound, and video that focus on IPV and safety behaviors (10). Digital storytelling has been 
advocated as a strategy to empower people and facilitate learning (42). The video will be culturally 
and linguistically adapted to Pakistani, Somalian and Norwegian women. The development of both 
the screening tool and the safety-promoting video will be based on several recourses: User 
participation as describe in chapter 6, IPV in primary care guidelines, systematic reviews of health-
care based interventions, meta-syntheses of qualitative studies and studies documenting inter-
cultural communication.  
 
Work package 2: Professional development for community- midwives and heath visitors regarding 
IPV 
We will organise meetings and short courses for community midwives and health visitors where 
other community services, which provide care for women experiencing violence will be invited. 
The aim of these meetings is to establish/improve/confirm contact and collaboration as well as 
increase health professionals knowledge about IPV. We will provide community midwives and 
health visitors with materials regarding IPV. For this purpose we will use local information (for 
example phone numbers to nearest crisis centre), material provided by the Health Directorate and 
some of the material by WHO (8). We will use interactive teaching methods such as role-play to 
increase health professional’s expertise in asking about violence. Other members of the community 
health team involved in this care will be part of the courses, i.e. social services, police etc. 
 
Work package 3: Perform a randomized controlled trial (RCT) within antenatal care. 
This RCT will take place in midwifery antenatal care in Oslo, Drammen and Akershus. For the 
study, the women will use the tablet with a screening tool for violence. Women disclosing IPV in 
standard care will receive information video about  general services for a safe pregnancy on the 
Work package 1: Develop the screening tool and safety-promoting video 
Work package 2:Professional development regarding IPV and educate the midwives to 
respond to the disclosure of IPV as a result of the study and the running of the study 
Work package 3: Perform an RCT within antenatal care 
- Outcomes at 3 months postpartum. 
Work package 4: Process evaluation: Including community midwives 
and women’s experience of the study using the tablet technology and the 
intervention 

 
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tablet including referral to a website with info on IPV. Exposed women in the intervention group 
will receive information about violence and the developed safety-promoting video on the tablet. 
Women who screen negative will get general information about a safe pregnancy on a small card 
 
Study flowchart:  
 
 
 
Inclusion /exclusion criteria: Pregnant women above 18 years at the participating midwifery 
offices: Women that understand Norwegian, English, Urdu or Somali. We will exclude women who 
are not possible to be screened alone and women who do not have the mental or physical capacity to 
answer the questions.  
Participant selection: The rationale for choosing the specific immigrant group is that Pakistani and 
Somali communities are among the largest immigrant groups in Norway. They have a high fertility 
rate, 3.9 and 3.0 respectively (26). Both countries of origin have patriarchal norms that may permit 

 
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IPV. In addition, Somali immigrants are regarded as a group with potential previous exposure to 
interpersonal violence due to the prolonged conflict situation in Somalia (43). 
Sample size: To detect a difference of 20% in the use of safety behaviours at 3 months post-partum 
(90% power, α 5%, two sided) we need to include 150 women, 75 in each group. Because of the 
nature of the intervention women cannot be blinded to the intervention. Midwives will be blinded to 
which intervention women receive.  
Baseline data collection: At baseline, all participants will be asked to answer socioeconomic and 
demographic questions, a quality of life instrument, questions regarding current health and 
questions about integration using Audio Computer Assisted Interview at the study site. In addition, 
they will be screened for violence with a modified version of the Abuse Assessment Screen (AAS), 
a five-item screening tool created to detect violence against pregnant women (44), adapted to this 
study. Women who screen positive for abuse will be asked to complete the Composite Abuse Scale 
(Revised) Short form (CASR-SF) (45), an instrument include 15 items regarding physical, 
emotional and sexual violence and questions about safety behaviors, based on the Safety Behavior 
checklist (10) that originally consist of 15 questions about safety behaviors,  
Outcome measurements: The primary outcome is the adoption of safety-promoting behaviours 
three months post-partum measured by an adapted Safety Behaviour Checklist. We have selected a 
short follow-up period based on literature that documents high rate of violence reoccurrence and 
increased vulnerability in early post-partum period (46). Quality of life is the second primary 
outcome, measured using WHO brief version of QOL. Secondary outcome measures are: 
Prevalence of IPV, symptoms of depression, maternal outcomes such as mode of delivery, birth 
experience and pain relief during labour. For the neonate we measure birthweight and 
breastfeeding. The follow-up after delivery will be administered at the public health station at the 
second appointment with the public health nurse in the vaccination program. Clinical and medical 
data will be self-reported by the participating women. All women that screen positive at the AAS 
will be followed up in addition to 2 controls per woman disclosing IPV. This will ensure that the 
women’s answer is confidential and ensure blinding for the recruitment sites, as they are informed 
that not only women reporting IPV but in addition a randomly selected number of women not 
reporting IPV are asked to fill out Q2 
 
Data management and analysis: All the identifiable data (name, phone number) and study number 
will be kept in a register for use during follow up study. This register will be locked up with access 
only available to the project leader. Other data, collected on the tablet, will be transferred to a secure 
server accessible only to the project group. Descriptive statistics (means, standard deviations, 
frequencies and percentages) will be used to describe the women. Differences between groups will 
be investigated using independent t tests and chi-square tests/Fisher’s exact test when appropriate. 
We will look at mean numbers of safety behaviours and determine changes over time by using 
repeated measure analyses of variance (RM ANOVA).  
 
Work package 4: Process evaluation: evaluate community midwives and women’s experience of 
participating in a study using tablet technology for screening for IPV and teaching safety 
The process evaluation will investigate the extend to which the intervention was delivered as 
intended, what worked and what did not work. Semi-structured, qualitative interviews will be 
performed with a purposively selected sample of midwives. The interviews will be audio recorded, 
transcribed and reviewed by the work package leaders for emerging themes, sub-themes and codes. 
Themes that emerge will be discussed in the regional research group. The same research process 
will be used to explore women’s experience of screening and the intervention.  
 
3. Project management, project management, organisation and cooperation 
 
  
 
WP1 
01.05.16–01.06.17 
WP2 
01.09.16–01.12.17 
WP3 
01.12.17–31.12.18 
WP4 
03.03.19–01.05.21 
Table 2 Overview over the involvement in the different people/groups in the different tasks  

 
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The project leader is Mirjam Lukasse, professor and midwife, currently principal investigator of a  
project funded by Norwegian Research Council also addressing immigrant women (47). The project 
is a RCT that successfully use App-technology and it is in the recruitment phase. 
Lukasse was the project coordinator of Bidens, an International study on violence against pregnant 
women (4, 18). Lukasse is currently main supervisor for a PhD student in Nepal where a similar 
project is in progress, using A-CASI. Lukasse was main supervisor for Lena Henriksen who did 
her PhD on sexual violence against women (3, 48). Professor Josef Noll will participate as an 
expert on information and communication technology and patient safety. Professor Noll is 
collaborator in the project where Lukasse is project leader (47). This project uses tablets to collect 
data in the same languages proposed in this study. Noll has vast experience with developing 
technical solutions (47, 49). Midwife and MPH Tine Aaserud has long experience from antenatal 
care and a master in health and empowerment. She is on the board of The Norwegian Midwifery 
association. She has an extended network among community midwives will be crucial in the 
recruitment of the health centres. She was in the external research group for the new violence 
guidelines (8). Postdoctoral fellow Lisa Garnweidner-Holme is an expert regarding cross-cultural 
communication, user-involvement and qualitative research methods and is currently a part of a 
large-scale project using App technology in antenatal care (47). Public health nurse and MPH 
Kirsten Jagmann from the Regional resource centre for violence, traumatic stress (RVTS) works 
with professional development and implementation of the violence guidelines. She has work and 
research experience regarding different immigrant groups in Norway (50).  
Nationally the project group will include obstetrician/gynaecologist, Professor Berit Schei. 
She has vast experience in research on violence and is currently principal investigator of a large-
scale global project on violence among pregnant women including Nepal and Sri Lanka. She was 
also member of the steering committee of WHO multi-county study on violence against women. In 
addition, we have established contact with different collaborators that will be an advisory reference 
group: NAKMI (The Norwegian Centre for Minority Health Research) who will advise us on 
cultural aspects, The Crisis Shelter Secretariat with input from social workers and legal advisors 
and RVTS with their expertise on violence and its consequences.  
Professor Angela Taft from the Judith Lumley Centre at La Trobe University, Melbourne 
will be an international expert advisor and collaborator. The Judith Lumley Centre is a centre 
for public health research in the field of mother and child and they have conducted RCTs in primary 
and antenatal care regarding IPV (39,51). A stay of 4 months by the postdoctoral student and 
shorter visits by the project leader and PhD student are planned thus strengthening our collaboration 
with Professor Taft and her unit. Professor Taft will visit Norway for teaching and supervision. 
This project has called together a core group of experts in the field of IPV among pregnant 
women. It hopes to contribute to the establishment of a regional network.  
 
Feasibility  
In Norway, almost all pregnant women attend antenatal care, a well integrated part of the public 
health program. Traditionally, the research burden regarding pregnant women is in a hospital 
setting, not in primary care. This makes it feasible to use primary care as the setting for this project. 
This project may help community midwives address some of the problems in implementing 
violence questions as a good clinical practice. Hence, the clinicians are motivated to help in the 
Staff involved 
Mirjam Lukasse, 
Josef Noll, Lena 
Henriksen, Lisa 
Garnweidner-Home  
Mirjam Lukasse, 
Lena Henriksen, 
Kirsten Jagmann, 
Tine Aaserud, PhD 
students  
Mirjam Lukasse, Lena 
Henriksen, PhD 
students, Master 
student in midwifery.  
Lisa Garnweidner-
Holme, Mirjam 
Lukasse, Lena 
Henriksen  PhD- and 
Master student(s) 
Expert input 
Berit Schei, Angela 
Taft, NAKMI 
Social services, 
Police, RVTS, Crisis 
Shelter staff 
Research assistant with 
technical expertise 
(UNIK) 
Berit Schei, Angela 
Taft 
User 
involvement 
 
Somali, Pakistani & 
Norwegian women 
Community midwives 
Community midwives 
Study participants, 
Community midwives,  

 
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recruiting process and the implementation of the study. Lukasse, Henriksen and Aaserud are 
midwives with long clinical practice and good knowledge of the Norwegian setting that will 
promote collaboration with the clinicians.  
Lukasse and Henriksen have informed community midwives about this possible new project at 
formal and informal meetings, and received very positive responses. Information about the planned 
project has been sent to all community health stations in Oslo. The research group consist of 
researches with comprehensive experience in initiating, leading and successfully finalizing similar 
projects. RVTS, part of our advisory reference group, works with different municipals regarding 
how to ask pregnant women about violence and will be a future collaborator in planning the 
implementation of the screening-tool.  
 
The PhD students 
HiOA established a PhD for health professionals in 2012. The research department at HiOA 
provides all necessary courses and a stimulating environment for PhD students. There are several 
midwife-PhD students already at the department of Nursing and Health Promotion. The midwifery 
education at HiOA has their own research group that has regular meetings including PhD students. 
Close collaboration with Professor Schei will allow for meetings with PhD students from NTNU 
and HiOA. Schei and Lukasse have collaborated in this way before. Henriksen will be main-
supervisor for the PhD students with the support from Lukasse as co-supervisor.  
 
Budget 
Costs and plan for finances are entered in the electronic application form. As Lukasse is project 
leader for a project using electronic tablet to collect data and translation to Urdu and Somali we 
have a realistic idea about the costs for this. Collaboration with users of the services and community 
health workers is central in this project which is reflected in the costs for meetings. We aim at 
strengthening international collaboration resulting in travel expenses. We apply for NOK 9 326 000 
from the research council, HiOA will fund NOK 2 696 000 of the project. ExtraStiftelsen finances 
part of this project by funding a post doctor, which within this budget results in NOK 1 710 000.  
 
4. Strategic and central perspectives 
Compliance with strategic documents: Both national and international strategic document 
supports a study that aims at reducing IPV (5, 22, 38, 52). A white paper from 2013 (Report to 
Storting) points to the prevalence of IPV and to the importance of reducing IPV (22). The white 
paper was followed by an action plan for 2014-2017 (38). Interventions that target IPV and the 
knowledge gap regarding IPV in immigrant groups are some of the highlighted areas in these 
strategic documents (22, 38).  
 
Relevance to society moved to chapter 6 as it is part of the specific issues of interest for this Call. 
 
Effect on the environment 
As we will use electronic tablets to collect data instead of questionnaires on paper, we actually 
reduce the use of paper. Reduced violence will reduce the need for healthcare and so have positive 
economic effect on society. We see no other effects on the environment. 
 
Ethical considerations 
The studies included in this project will follow the Helsinki Protocol (WMA Declaration of 
Helsinki at www.wma.net). It will be sent to the Norwegian Regional Committees for Medical 
Health Research Ethics South East (REK) and Data Inspectorate for approval. WHO has suggested 
guidelines for researching violence against women: Putting women’s safety first: Ethical and Safety 
Recommendations for Research on Domestic Violence against women (53) that will be followed. In 
cross-cultural research on violence researchers may be less familiar with the culture(s) and have a 
poorer understanding of the ways the research could cause harm. This project will include 
collaborators that have a deeper knowledge about cultural differences in order to prevent harm. 
Questions about violence are sensitive, but studies have shown that women are willing to answer 

 
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questions about abuse and they report meaningfulness about their participation in studies that 
includes questions about sensitive topics (54). All participants will get information about recourses 
in their community regarding violence. The community health services are equipped to care for 
women suffering from IPV who request and need help. Routines and procedures are in place. Our 
study should not add any risk. On the contrary, the extra education provided to midwives at the start 
of the study should enable midwives to access the resources available in the health services.  
 
Gender perspective 
This project is in its very nature one for women, as we aim to reach pregnant women in antenatal 
care. It will benefit their children if they can live a safer life due to an intervention during 
pregnancy. As such, it will benefit both genders. There are few male midwives and health visitors in 
Norway and many female family doctors. Involving men in this project is a challenge. However, 
Professor Noll and our collaborator at NAKMI community doctor Arild Aambø are both a male.  
 
5. Communication and dissemination 
Communication with users of the primary care services, professional groups and the public 
We will invite users of antenatal care to language specific meetings to inform them about the study. 
We will establish a website to publish results. We will present our results at seminars, meetings, 
conferences and use any opportunity to disseminate results. We will prioritize meetings with civic 
society organizations such as the Norwegian women’s Public Health Association and violence 
against women campaign groups. 
 
Scientific publications 
The project is expected to produce the following scientific papers (working preliminary titles): 
1. Development of a culturally adapted screening tool and intervention to prevent intimate partner 
violence among Norwegian, Pakistani and Somali women. Violence Against Women 
2. Preparing for the worst – promoting safety behaviours in antenatal care among Norwegian, 
Pakistani and Somali pregnant women. A randomised controlled trial, protocol. BMJ Open 
3. Preparing for the worst – results of a randomised trial in antenatal care among Norwegian, 
Pakistani and Somali women in Norway we will try The Lancet but expect to publish in BMJ Open 
4. Midwives’ experience of participating in a study using tablet technology to screen for IPV and 
tablet technology to teach women safety behaviours Midwifery 
5. Women’s experience of screening for violence Journal of Sexual and Reproductive Health 
6. Women’s experience of receiving an information video promoting safety behaviours Birth.  
Depending on recruitment and results we will publish separate papers on the results on Pakistani, 
Somali and Norwegian women, in particular for the qualitative papers on their experiences. 
 
6. 1. User participation 
Users are involved in all phases of the project (see table 2, page 6). Pregnant women, community 
midwives and members of the reference and research group will be involved in the development of 
the intervention content by demonstration of prototype. They will also be asked about the adapted 
screening tool for violence and interviewed about which actions that increase safety and participate 
in the digital storytelling. Our reference group will ensure contact with appropriate, key informants. 
The reference group consisting of crisis centre advocates will be consulted to obtain knowledge 
about safety-promoting behaviours and existing services and NAKMI will contribute regarding 
cross-cultural adoption of the intervention. 
 
6.2. Anticipated benefits to users and society at large 
We belief victims of violence will have a greater chance to experience a reduction in violence 
through the safety behaviours learned and applied and improved care, as health professional receive 
extra skills and knowledge. Violence against women has a negative effect on women themselves, 
their families, children and society as a whole. Women experiencing violence are more likely to 
have poorer health, become isolated, have sick leave, and require medical care. IPV may be 
observed by children and may lead to violence against the children in the family. This may result in 

 
10
poor health for children, absence from school, poorer education and long-term effects for these 
children. Therefore is breaking the circle of violence of benefit for society as a whole. 
The screening tool and videos developed can easily be implemented in other communities 
across the country and may even be useful for Somali and Pakistani women outside of Norway. The 
safety-promoting video will be made available for everybody through a website, which also 
instructs women how search without leaving a search-log for their own security.   
Health staff will experience a greater competence and confidence in approaching the topic of 
violence and handling positive answers. Women will benefit from health professionals who enquire 
in an appropriate way about violence.  
 
7. References:  
1. 
Vangen S, Ellingsen L, Andersgaard AB et al. Maternal deaths in Norway 2005-2009. Tidsskrift for den 
Norske laegeforening 2014;134:836-9. 
2. 
Garcia-Moreno C, Pallitto C et al. Global and regional estimates of violence aganist women: prevalence and 
health effects of intimate partner violence and non-partner sexual violence. Geneva: 2013. 
3. 
Henriksen L, Vangen S, Schei B, et al. Sexual violence and antenatal hospitalization. Birth. 2013;40:281-8. 
4. 
Schei B, Lukasse M, Ryding EL, et al. A history of abuse and operative delivery--results from a European 
multi-country cohort study. PloS one. 2014;9(1):e87579. 
5. 
WHO. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy 
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