The authors have declared that no competing interests exist.
The Democratic Republic of the Congo (DRC) has experienced nearly two decades of civil conflict in the Eastern regions of North and South Kivu. This conflict has been notorious for the use of sexual violence as a weapon of war, leading in many cases to pregnancy after rape. The objectives of this analysis were: 1) to describe patterns of sexual violence-related pregnancy (SVRP) disclosure; 2) to consider why survivors chose to disclose to particular individuals; and 3) to examine the dialogue around SVRPs between women with SVRPs and their confidants. In South Kivu Province, Democratic Republic of Congo, two sub-groups of sexual violence survivors completed qualitative interviews, those currently raising a child from an SVRP (parenting group, N = 38) and those who had terminated an SVRP (termination group, N = 17). The findings show that a majority of SVRPs were conceived when participants were held in sexual captivity for prolonged periods of time. The SVRPs were disclosed to friends, family members, other sexual violence survivors, community members, spouses, health care providers, or perpetrators. The confidants were most often chosen because they were perceived by the participants as being discreet, trusted, and supportive. The confidants often provided advice about continuing or terminating the SVRP. Trust and discretion are the most important factors determining to whom women with SVRPs disclose their pregnancies. The vital role of confidants in giving support after disclosure cannot be overlooked. Providing opportunities for survivors to safely disclose their SVRPs, including to health care providers, is a necessary first step in allowing them to access safe and comprehensive post-assault care and services.
Sexual violence has been prevalent during two decades of armed conflict in eastern Democratic Republic of Congo (DRC). [
Previous studies in eastern DRC suggest that women with sexual violence-related pregnancies (SVRPs) also face a high burden of psychosocial consequences such as spousal abandonment [
Much of the related literature focuses on disclosure of sexual assaults (as opposed to SVRPs) and comes from Western populations. For instance, research has shown that sexual violence survivors are more likely to disclose to formal entities including law enforcement and health care providers, when the assault is perpetrated by a stranger or use of a weapon. [
Even less is known about disclosure of SVRPs in conflict or post-conflict settings where access to health care is often restricted, resources for post-sexual assault care are limited and stigma surrounding sexual violence is high.[
The data presented here is derived from a mixed methods study conducted in Bukavu, South Kivu Province from October to November, 2012. The study was designed to assess women reporting SVRPs who were currently raising a child from an SVRP (parenting group) and women who had terminated an SVRP (termination group). Respondent-driven sampling (RDS), a peer-recruitment method designed to sample hard-to-reach populations, was used to recruit a total of 852 participants to complete a quantitative questionnaire. Every twentieth participant in the parenting group and every fifth participant in the termination group also completed a qualitative interview. Although respondent-driven sampling (RDS) was used to recruit participants, the qualitative data represent a convenience sample due to smaller sample sizes. Quantitative data [
Women who self-identified as survivors of sexual violence since the start of the war (~1996), became pregnant as a result of sexual violence, and were aged 18 years or older were identified by local partner organizations for inclusion in this study. The parenting group included women who had delivered a live born infant as a result of an SVRP and were living with and raising the child at the time of the study. Women were excluded from this group if they reported a stillbirth, if the child had since died, or if the child was not living with or in the care of the mother at the time of the study. Participants who self-reported termination of an SVRP were included in the termination group. Women with SVRPs that reported spontaneous abortions were excluded. Women with a history of more than one SVRP were eligible for both the parenting and termination groups.
Qualitative questionnaires designed for each study group were comprised of semi-structured questions on pregnancy history, sexual violence and experiences related to the SVRP, disclosure of the SVRP, and decision-making process regarding continuing or terminating the SVRP [
Transcripts of the interviews were translated into English by a local translator and electronic files were created and subsequently uploaded to the qualitative data analysis software Dedoose [
The institutional review board at Harvard School of Public Health approved this study and a community advisory board provided study oversight in Bukavu. The Medical Inspector in South Kivu provided permission to conduct the study. No identifying information was collected from study participants and verbal informed consent was obtained prior to enrollment. If the participant agreed to take part in the study after having the informed consent explained and after having an opportunity to ask questions, consent was indicated by checking a box on the electronic quantitative survey. Participants were offered a headscarf ($1 USD) as compensation for their time and transportation reimbursement (up to $8 USD return) was provided directly to taxi drivers. Participants also received a referral card for medical care and/or mental health counseling and a trained psychosocial assistant was available during all interviews to provide assistance to any participants who were distressed or who requested counseling during or after the interview.
A total of 38 and 17 interviews were completed with participants in the parenting and termination groups, respectively. The mean age of all 55 respondents was 33.5 (18–60 years). The total number of pregnancies per woman ranged from 1–12 (mean 4.6) and the number of living children per woman at the time of the survey ranged from 1–9 (mean 3.9). Many women reported they were divorced or separated from their spouses as a result of sexual violence (16/55). Participants also identified as widowed (13/55), married (11/55), single or never married (11/55) or reported their husbands missing (4/55). Some women in the married group also reported their husbands were kidnapped and were unsure if their husbands were alive at the time of the study.
Participants were asked to whom they had first disclosed the SVRP and if they subsequently told anyone else about the SVRP. Women in both study groups reported disclosure to friends or community members, typically described as a
There were several reasons given for disclosing the SVRP to specific individuals. Regardless of whether the confidant was a family member, neighbor, or spouse, women in both the parenting and termination groups chose their confidant because they believed this individual was discrete and could be trusted not to disclose to others.
20-year-old woman, not married and raising a child born from an SVRP
25-year-old woman, abandoned by her spouse who terminated an SVRP
24-year-old woman, married and who terminated an SVRP
Participants also indicated that they chose to disclose to a particular individual because they were close to him / her and because they were confident that they would be comforted and supported by this person.
36-year-old woman, not married and parenting a child born from an SVRP
37-year-old women, abandoned by her spouse and raising a child born from an SVRP
Among the women who did not disclose to anyone, lack of trust was cited as a reason for not disclosing the SVRP. One woman who did not disclosure the pregnancy reported moving to another location where she believed she could more easily conceal that it was an SVRP.
36-year-old woman, widowed, who terminated an SVRP
48-year-old woman whose spouse was kidnapped and was raising a child born from an SVRP
Women who experienced sexual captivity by armed combatants often met other women while in captivity and participants reported that they chose to disclose the SVRP to another survivor of sexual violence because they trusted the woman or felt that the other survivors had had a similar experience and might be able to provide advice.
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33-year-old woman, separated from her spouse, raising a child from an SVRP
25-year-old woman separated from her spouse, raising a child form from an SVRP
In some cases, the woman disclosed to another survivor who had also become pregnant as a result of sexual violence.
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52-year-old woman, married and who had terminated an SVRP
Some women reported that they informed the sexual violence perpetrator about the pregnancy. A subset of these women reported they were ridiculed by the perpetrators while another participant reported that she was beaten upon disclosing the pregnancy. Other participants reported that the perpetrators simply did not care that they were pregnant.
20-year-old woman, not married and raising a child born from an SVRP
37-year-old woman, married and who terminated an SVRP
26-year-old woman, not married and raising a child born from an SVRP
A few women had informed a health care professional about the SVRP or a traditional healer. In such cases, women often discovered that they were pregnant after seeking care at a local health facility or while they were in the hospital for other non-pregnancy related injuries.
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48-year-old woman, separated from her spouse, raising a child from an SVRP
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40-year-old woman, hospitalized for a leg injury from the [combatants] raising a child from an SVRP
Women in the termination group who sought out a medical provider, stated that they chose to do so in part because they felt the provider was discreet or they wanted to ensure they received good medical care again highlighting how themes of discretion and trust in the confidant may have influenced disclosure patterns.
21-year-old woman, not married, who terminated an SVRP
33-year-old woman, whose husband was killed by [combatants] and who terminated an SVRP
In further probing why women chose to disclose to certain individuals, information about the content of discussions with confidants also emerged. When describing why a confidant was chosen, women in both groups often confided in individuals whom they thought would know what to do, in particular in relation to continuing or aborting the pregnancy, and sought and relied on the advice of their confidants.
30-year-old woman, whose husband was kidnapped by [combatants] and who terminated an SVRP
In many instances, women went on to explain how the advice from their confidants ultimately influenced their decision to either continue or terminate the pregnancy.
40-year-old woman, married and who had terminated an SVRP
32-year-old woman, separated and raising a child from an SVRP
While in other situations, the woman decided to go against the advice she received from her confidant.
25-year-old woman, married and raising a child born from an SVRP
Following disclosure of the SVRP, discussion between the woman and her confidant(s) often turned to religion and/or innocence of the unborn child.
40-year-old woman, widowed and raising a child born from an SVRP
35-year-old woman, separated and raising a child born from an SVRP
Potential social consequences, such as spousal rejection, were common themes that emerged among women who disclosed to their spouses. Of the seven women who informed their spouses about the SVRP, six reported that they were asked or pressured to terminate the pregnancy and/or rejected by their spouse.
37-year-old woman, abandoned by her spouse and raising a child born from an SVRP
27-year old woman married who terminated an SVRP
One woman who disclosed the pregnancy to her spouse was later abandoned by him after deciding to continue the pregnancy to term.
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37-year-old woman, abandoned by her spouse raising a child born from an SVRP
These qualitative data highlight that sexual violence survivors with SVRPs may disclose the pregnancy to a variety of personal contacts, including friends, family members, neighbors, highly regarded community members, other survivors of sexual violence or the sexual violence perpetrators. The most important considerations influencing whom to inform were discretion and trust, feeling close to the individual, knowing that the individual would be supportive, and a perception that the confidant would know what to do in the situation. Some confidants advised the participant to carry the pregnancy to term while others advised the participant to terminate the pregnancy.
Confidentiality was a particular theme throughout and should be considered in the context of previous research on stigma among sexual violence survivors and women with SVRPs in eastern DRC. [
In a report on children conceived from sexual violence in North Kivu Province, DRC Liebling described her observation that older women were less likely to disclose the pregnancy.[
Women who disclosed to their spouses were either asked to terminate or were rejected by their spouses as a result of sexual violence and/or the SVRP. It should be noted however, that currently married women were under-sampled in the qualitative parenting survey in comparison to the quantitative parenting survey (5% versus 32%). It is unknown how this could affect the results as we may have failed to capture married women who had disclosed to their spouses and were still married while raising the child born from an SVRP.
A number of women who were in captivity reported disclosure of the SVRP to the perpetrator. These participants did not provide a specific reason for disclosing to the perpetrator although there are several hypotheses. First, women may have hoped the perpetrator would release them from captivity upon learning about the pregnancy. Second, women may have hoped that the perpetrator would provide some assistance with the pregnancy, such as access to medical care. Or finally, some women may have hoped that the perpetrator would provide support in raising the child.
In this sample, it was rare for women to disclose SVRPs to health care providers and although the context is very different, this finding is similar to that reported by North American researchers who have found that assault survivors were more likely to disclose to informal support providers such as friends and family than to health care providers. [
In general, early disclosure of sexual assaults to formal support providers is recommended as it allows for evidence collection and for prompt emergency medical care.[
The qualitative data presented here are derived from a larger sample of participants recruited through respondent-driven sampling (RDS). The results represent only the attitudes and experiences of those interviewed and are not generalizable. Comparison of demographics between the quantitative and the qualitative interviews indicates that married women raising children from SVRPs were under-sampled in the qualitative interviews. It is unknown what other differences in sampling may have existed. Responses were hand recorded, and errors and biases may have occurred in transcription. Some nuances may also have been lost since the responses were not audio-recorded. Translation and interpretation errors may exist in these data, although every effort was made to assure fidelity to the context during translation, analysis and interpretation. Responses may have been influenced by the interviewers’ own biases and perceptions and the presence of the interviewer may have in turn impacted the response. Recall bias among study participants may have also been an issue. Efforts were made, however, to hire and train interviewers who were well versed in qualitative research methods, comfortable with the sensitivities of the subject matter and cultural norms, and knowledgeable in how to probe for more accurate recall. Finally, as with all qualitative research, there may also be interpretation bias by coders and researchers.
The study also had a number of strengths including accessing a relatively large sample (N = 55) of a hard-to-reach population in an insecure, post-conflict setting. Its mixed methods design also allowed us to draw on knowledge gained in the quantitative data when interpreting the qualitative narratives. The study was also unique in that it offered the opportunity to gain insights on disclosure of SVRPs from both women who carried the pregnancies to term as well as of women who had terminated SVRPs.
Trust and discretion are the most important factors determining to whom women with SVRPs disclose their pregnancies. The vital role of confidants in giving support after disclosure cannot be overlooked. Providing opportunities for survivors to safely disclose their SVRPs is a necessary first step in allowing them to access safe and comprehensive post-assault care and services. Further research is warranted to better understand why few women disclosed to health care providers in this particular context.
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We are grateful to our partners: Centre d’Assistance Médico-Psychosociale (CAMPS), Acteurs Dans le Development et Droit a la Sante Pour Tous (ADES) and Action Pour la Lutte Contre L’Ignorance du SIDA (ALCIS). We would like to thank colleagues at the Harvard Humanitarian Initiative (HHI) as well as Daisy Njebenje, Amani Baro and Ideumbo Kasigwa. This study was funded by the Eleanor Miles Shore Foundation at the Harvard Medical School and by generous donations to Harvard Humanitarian Initiative (HHI).