"Other Patients Are Really in Need of Medical Attention"-The Quality of Health Services for Rape Survivors in South Africa

By Christofides, Nicola J.; Jewkes, Rachel K. et al. | Bulletin of the World Health Organization, July 2005 | Go to article overview

"Other Patients Are Really in Need of Medical Attention"-The Quality of Health Services for Rape Survivors in South Africa


Christofides, Nicola J., Jewkes, Rachel K., Webster, Naomi, Penn-Kekana, Loveday, Abrahams, Naeema, Martin, Lorna J., Bulletin of the World Health Organization


Introduction

Rape is an important public health and human rights concern. Its consequences include unwanted pregnancy, unsafe abortion, genital fistulae, pelvic inflammatory disease, sexually transmitted infections such as HIV/AIDS, depression, post-traumatic stress disorder, suicidal behaviour and being socially ostracized (1). These problems are starkly visible in South Africa, which has the highest worldwide annual prevalence of rape reported to the police. Despite documented under-reporting (2), data indicate that in 2002-03 there were 52 425 cases of rape (115 per 100 000 population) reported to police in South Africa compared to, for example, 31.8 per 100 000 in the United States or 8.5 per 100 000 in Brazil (3, 4). In South Africa, we have had reports that patients present to health facilities but do not report the tape to the police. No studies have systematically collected data on how many patients do this.

A key challenge for public health services is to provide adequate gender-sensitive health care for rape survivors within the constraints imposed by locally available resources. In South Africa and other developing countries concerns have been voiced as to how rape survivors are cared for (2, 5). Research on health services for rape survivors can be useful in enhancing the visibility of such problems and improving the quality of care.

Until 1999 in South Africa designated doctors (known as district surgeons) were contracted by the State to deliver care for rape survivors. The services provided by district surgeons were riddled with problems and had been criticized by women's health advocates for many years. An investigation in 1997 by Human Rights Watch found that there was little incentive for district surgeons to "do a good job" (6). The investigation also found that the system was "deeply flawed with problems of inaccessibility, prejudice and lack of training at all levels" (6). There were often long waits for services, with 1 in 5 patients waiting longer than 5 hours to see a district surgeon after reporting the rape to the police (7).

In 1999 in an effort to improve services and move towards more integrated care, and in keeping with a primary health care approach (8), district surgeons were abolished. Currently, any doctor in public or private practice can provide health services for a rape survivor. However, an exploratory study of services in one province found that changes to services had been made without taking account of the necessity for formal training or for the practitioner to provide evidence of competence. Many doctors were thus ill equipped and reluctant to conduct examinations of rape survivors (9).

It is against this background that an investigation into the quality of services for rape survivors provided by the public health sector in South Africa was undertaken for the Department of Health. Our study aimed to describe aspects of service quality, determine where the best services were provided (whether in tertiary, regional or district hospitals), and to determine which factors influenced the quality of services.

Ethical approval for the study was obtained from the University of Pretoria ethics committee, and the provincial departments of health allowed us to have access to the hospitals.

Methods

Sampling

A cross-sectional study of facilities in all nine provinces of South Africa was undertaken. Two district hospitals, a regional hospital and a tertiary hospital (in provinces with one or more tertiary hospitals) were randomly sampled in all provinces (n = 31) with a probability proportional to the stratum size in each province. The sampling frame consisted of 155 hospitals.

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At each hospital, the medical superintendent, head of nursing or both were approached and asked to identify for interview two doctors and two nurses who examined or assisted in caring for patients who presented after being raped. …

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