Anguzu et al. BMC Health Services Research (2022) 22:283 https://doi.org/10.1186/s12913-022-07669-0 RESEARCH Facilitators and barriers to routine intimate partner violence screening in antenatal care settings in Uganda Ronald Anguzu1*, Laura D. Cassidy1, Kirsten M. M. Beyer1, Harriet M. Babikako2,3, Rebekah J. Walker4,5 and Julia Dickson‑Gomez1  Abstract  Background:  Uganda clinical guidelines recommend routine screening of pregnant women for intimate partner violence (IPV) during antenatal care (ANC). Healthcare providers play a critical role in identifying IPV during pregnancy in ANC clinics. This study explored facilitators and barriers for IPV screening during pregnancy (perinatal IPV screening) by ANC-based healthcare workers in Uganda. Methods:  We conducted qualitative in-depth interviews among twenty-eight purposively selected healthcare providers in one rural and an urban-based ANC health center in Eastern and Central Uganda respectively. Barriers and facilitators to IPV screening during ANC were identified iteratively using inductive-deductive thematic analysis. Results:  Participants had provided ANC services for a median (IQR) duration of 4.0 (0.1–19) years. Out of 28 health‑ care providers, 11 routinely screened women attending ANC clinics for IPV and 10 had received IPV-related training. Barriers to routine IPV screening included limited staffing and space resources, lack of comprehensive gender-based violence (GBV) training and provider unawareness of the extent of IPV during pregnancy. Facilitators were availability of GBV protocols and providers who were aware of IPV (or GBV) tools tended to use them to routinely screen for IPV. Healthcare workers reported the need to establish patient trust and a safe ANC clinic environment for disclosure to occur. ANC clinicians suggested creation of opportunities for triage-level screening and modification of patients’ ANC cards used to document women’s medical history. Some providers expressed concerns of safety or retaliatory abuse if perpetrating partners were to see reported abuse. Conclusions:  Our findings can inform efforts to strengthen GBV interventions focused on increasing routine peri‑ natal IPV screening by ANC-based clinicians. Implementation of initiatives to increase routine perinatal IPV screening should focus on task sharing, increasing comprehensive IPV training opportunities, including raising awareness of IPV severity, trauma-informed care and building trusting patient-physician relationships. Keywords:  Intimate partner violence screening, Antenatal care services, Barriers and Facilitators, Health service delivery © The Author(s) 2022. 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The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Background Intimate partner violence (IPV) is a pervasive yet pre- ventable global health problem which refers to actual or threatened abuse by an intimate partner that may be physical, sexual, psychological, or emotional in nature [1]. In Uganda, IPV rates among women of reproductive Open Access *Correspondence: ranguzu@mcw.edu 1 Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, Wisconsin, USA Full list of author information is available at the end of the article http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/publicdomain/zero/1.0/ http://creativecommons.org/publicdomain/zero/1.0/ http://crossmark.crossref.org/dialog/?doi=10.1186/s12913-022-07669-0&domain=pdf Page 2 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 age (15–49 years) are high at 29.3%, 22.5%, and 16.6% for psychological, physical and emotional IPV respectively [2] while, 10.6% of women experience IPV during preg- nancy (perinatal IPV) [2]. Regional differences show a higher IPV prevalence among pregnant rural residents (11.4%) compared to their urban counterparts (8%) [3]. Exposure to IPV during pregnancy increases the risk for low birth weight babies, premature rupture of mem- branes [4], induced abortions [5, 6], HIV acquisition [7, 8], IPV-related injury [3] and disability [9, 10]. Address- ing IPV merits the involvement of healthcare systems to detect and prevent morbidity and mortality associ- ated with IPV among vulnerable populations, including perinatal IPV survivors [11, 12]. Evidence shows that IPV screening effectively reduces depressive symptoms and improves some pregnancy outcomes [13]. Implementa- tion of effective programs are essential in order to rou- tinely detect and respond to IPV during pregnancy [14]. Antenatal care (ANC) clinics present an opportune set- ting to screen for perinatal IPV in women seeking ANC services. IPV is a form of gender-based violence (GBV) in which abusive behavior is perpetrated towards survivors based on differences in power dynamics within an intimate relationship [15]. In this paper, we use IPV except for cases in which the larger concept of GBV is more appro- priate, such as the GBV training given to healthcare pro- viders, which includes detecting and responding to all forms of GBV such as sexual assault against strangers or when used by participants in quotations. The World Health Organization (WHO) recommends that pregnant women attend a minimum of eight ANC visits in order to optimize maternal, fetal and newborn health outcomes [16], which includes routine IPV screen- ing in ANC clinics. The Uganda Clinical Guidelines (UCG) recommends IPV screening in healthcare settings to be conducted comprehensively alongside screening for chronic medical conditions such as hypertension dur- ing pregnancy (pre-eclampsia), and gestational diabetes among others [17]. These WHO and UCG recommen- dations are promising public health interventions that may reduce the occurrence of adverse maternal and child health outcomes due to timely detection of risk factors in early gestation. The process of provision of routine ANC services in Uganda involves triaging, group health educa- tion, consultation that includes detailed history taking, physical examination, conducting diagnostic laboratory or radiological testing, whole management involves pro- viding any needed medical treatment and appropriate referrals. Provider administered IPV screening may be provided along this continuum of care specifically dur- ing triage and clinical consultations. Although healthcare provider screening, counseling and management of IPV during ANC are prevention efforts recommended to be conducted within healthcare settings [7, 17, 18], anec- dotal evidence suggests that during patient-physician assessments, ANC providers usually focus on obstetric risk screening only. Such clinical practices may increase the likelihood of perinatal IPV going undetected and untreated due to overlooking subtle or overt signs related to IPV. Several studies that describe the challenges as well as the facilitators for IPV screening by healthcare workers have been conducted in high income countries (HIC) [19–22]. Some barriers to IPV screening from stud- ies conducted in HIC included lack of provider training on IPV, few healthcare workers who receive specialized training in IPV, time constraints, inadequate privacy during clinical assessments as well as poor employer support of healthcare providers [23]. Due to the com- plexity of risk factors and prevention strategies for IPV, systems-level interventions have been proposed. There is paucity of evidence from Low and Middle Income Coun- tries (LMICs) [24, 25], including Uganda, [26–29] that describes whether or how healthcare providers screen for IPV among populations of women seeking ANC services. The National Policy on Elimination of Gender-Based Violence (GBV) of Uganda provides a policy frame- work aimed at addressing critical gaps in Uganda’s GBV response [30]. This includes guiding the multi-sectoral and multi-institutional implementation of comprehensive GBV prevention measures by state and non-state actors such as coordinating support and referrals between health, social, and law enforcement sectors. Screen- ing for IPV in healthcare settings presents unique chal- lenges due to the socio-cultural context within which IPV is perpetrated and condoned. Women may be deterred from disclosing IPV because of traditional practices such as bride price, which reduces women’s independence in decision making to seek supportive care for perinatal IPV [31]. In fact, referral of IPV survivors by healthcare pro- viders and Village Health Teams is low partly due to low IPV identification [3]. However, while many women do not seek help after experiencing IPV, they are still more likely to seek healthcare than other supportive services. A national survey conducted in Uganda found that 10.5% of women who experienced IPV used health services fol- lowing violence, 8.5% reported to local councils, 2% noti- fied police, 0.7% sought social services and 0.2% sought legal proceedings [3]. Limited support- or care- seeking behavior following IPV exposure reduces the chances of being screened for IPV. This national survey did not assess the extent of IPV disclosure among care seek- ing IPV survivors in Uganda. However, a mass-media, ‘edutainment’ experiment aimed at changing norms and behaviors in one rural community in Uganda showed Page 3 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 an increase in willingness to disclose IPV despite not reducing their acceptance of IPV [32]. Results from a randomized clinical trial to increase IPV screening in healthcare settings were inconclusive [33]. It is impera- tive that perinatal IPV is prioritized as a critical pub- lic health challenge that necessitates commitment and multi-institutional responses at national, health facility and community levels. An in-depth understanding of the challenges and ena- blers experienced by health facility-based providers to IPV screening using multi-level frameworks is essential in order to advance the roles healthcare providers play in implementation of IPV prevention and response strat- egies. In order to address this knowledge gap, our study examined facilitators and barriers to IPV screening by healthcare providers during ANC in rural and urban Uganda. Methods Study design and setting This health facility-based, qualitative study was con- ducted among twenty-eight healthcare providers in two public health facilities in rural and urban settings of Uganda. One study site is Luuka district, a predomi- nantly rural area located in the Busoga sub-region of Eastern Uganda with a total population of 238,020 [34]. Luuka district is mostly engaged in agricultural activi- ties, specifically growing sugarcane as their main com- mercial activity. The other study site is Kisenyi division, an administrative area of Kampala Capital City Author- ity (KCCA), located in the central sub-region of Uganda with a population of 338,665 or (20.4%) of the total KCCA population [34]. Kisenyi is predominantly urban with industrialized areas and several informal (slum) settlements. Informal housing settlements are areas of unplanned, unauthorized settlements where housing units are constructed on land occupied illegally or where the occupants have no legal claim and the housing not in compliance with building regulations [35]. Sample and recruitment Two health facilities at health center IV (HCIV) level were purposively selected from Luuka district and Kise- nyi division of KCCA in accordance with the hierarchy of Uganda’s health referral system because HCIVs pro- vide comprehensive emergency obstetric and neonatal care (CEmONC) services [36]. These CEmONC services include the following signal functions at health facili- ties: (i) performing surgery such as caesarian sections and providing blood transfusions in addition to provid- ing basic Emergency Obstetric and Neonatal Care [37]. Kiyunga HCIV is the main referral healthcare facility in Luuka district while Kisenyi HCIV has the highest patient turnover among HCIVs in KCCA. These two healthcare facilities were purposively selected because one was rural (Kiyunga HCIV) and the other urban (Kisenyi HCIV) in addition to potential differences in barriers and facilita- tors to routine IPV screening. The daily duty rosters were used to purposively select healthcare providers in ANC clinics. The first author and interviewer introduced the study to the health facil- ity in-charge and clinicians either in-person or through phone calls to introduce the study and establish the pro- viders’ willingness to participate. Participants were told that their decision to participate was voluntary and was not shared with supervisors. Willing participants chose convenient dates, times and locations within ANC clinics for the interviews. Rooms in ANC clinics for interviews were private and without interruption. On the inter- view day, written informed consent was obtained before data collection in which confidentiality and privacy were upheld. The interviewer presented letters of ethical clear- ance from The AIDS Support Organization (TASO) IRB, Medical College of Wisconsin (MCW) IRB and Uganda National Council of Science and Technology (UNCST) and letters of administrative permission from the Direc- tor of Public and Environmental Health at KCCA and the District Health Officer of Luuka district in-charges of ANC units in order to conduct interviews in the respec- tive selected district health facilities. The twenty-eight licensed healthcare workers that were initially contacted and accepted to participate were purposively selected to reflect a range of experiences and clinical training to provide ANC services including obstetric and gynecological care, health education and promotion of reproductive health. Data were collected in a period of ten days in Luuka district and fifteen days in Kisenyi, Kampala. The Daily duty rota contained a list of all on-call providers in ANC each week, therefore provid- ing the sampling frame from which to identify, introduce the study to (physically or by phone) and invite providers approached to participate in the study. After introducing the study, participants were asked to take a few days to think about participating before making their decision. Interviews stopped when the interviewer observed that no new information was being reported; hence satura- tion was achieved at 28 respondents. All participants approached were willing and participated in the study. These healthcare providers included obstetricians and gynecologists, general physicians/medical officers, and midwives. Certificate- and diploma-level midwives who provided ANC services were interviewed. Certificate- level midwives are healthcare providers, referred to as enrolled midwives, who receive one-year professional midwifery training. Diploma-level midwives, referred to as Assistant Nursing Officers, are those who received Page 4 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 two-year midwifery training. Two Obstetricians/ Gynecologists (OBGYN) were recruited from one purpo- sively selected national referral hospital to ensure cred- ibility of our findings from the sampled population. Data collection procedure To investigate the facilitators and barriers to healthcare provider screening for IPV among pregnant women dur- ing ANC, we conducted in-depth interviews. All inter- views were conducted in English. In-depth interviews were audio recorded and lasted an average of 60  min. Interviews were conducted by RA who is trained and experienced in collecting qualitative data. Field notes were taken during or immediately after each interview. The in-depth interview guide contained questions and probes about clinical practice and experiences of ANC services offered from the provider’s perspective. In‑depth interview guide The multi-level framework by Chaudoir and colleagues [38], guided development of the in-depth interview guide. We pre-tested our in-depth interview guide on three respondents in one urban based ANC facility other than the two selected health units. The in-depth inter- view guide asked questions that were categorized into provider-, partner-, and organizational-related charac- teristics and referral practices. Questions about pro- vider-related characteristics included healthcare worker training, clinic workload, work hours and competing pri- orities. Our in-depth interview guide also probed provid- ers’ attitudes towards IPV survivors and feelings about their vulnerability. Questions about patient characteris- tics from the providers’ perspectives included whether IPV survivors disclose IPV or not and potential reasons why. We probed for whether providers routinely or con- sistently screen for IPV during each ANC visit and the extent of IPV screening and referral practices. Generally, routine IPV screening varies in definition ranging from screening at every visit, every first ANC visit or every annual exam [39]. However, for this study, we defined routine IPV screening as screening for IPV at every ANC visit. In addition, timing of women’s first ANC visit, male partner ANC attendance and the burden of perinatal IPV among women attending ANC were explored. First, our in-depth interview guide asked provid- ers what prompts their suspicion of IPV. We asked for suggestions or recommendations on how to increase providers’ identification of IPV during pregnancy. Par- ticipants were asked to narrate their personal experi- ences and the training they received for managing perinatal IPV survivors. Secondly, our in-depth inter- view guide also included questions regarding whether referrals for specialist services for IPV and follow-ups are made. In addition, we asked providers about any factors that facilitate or impede routine IPV screen- ing by providers in ANC clinics. We also probed for whether gaps exist between usual screening practices for IPV by clinicians and recommendations from UCG [17]. Thirdly, partner-related probes explored charac- teristics of women’s partners that may impede women from disclosing IPV. In addition, we elicited sugges- tions from providers on how to improve IPV disclo- sure to healthcare workers as well as how the safety of perinatal IPV survivors may be addressed. Fourthly, we probed for organizational factors, including the avail- ability and extent to which clinical guidelines on IPV screening and referral were implemented, the avail- ability of IPV screening tools and clinic scheduling. Qualitative data analysis All interviews were transcribed verbatim. Transcripts were then analyzed using MAXQDA® a qualitative data analysis software [40]. The transcripts were read and re-read in a staged, iterative process in order to iden- tify emerging codes by two study team members. These two coders were RA, a doctoral candidate in public and community health, and licensed general medical doctor in Uganda and JDG an experienced anthropologist and global health researcher at the Institute for Health and Equity, MCW. In the initial phase of analysis, themes determined a priori were adapted from the multi-level framework to predict implementation outcomes developed by Chaudoir and colleagues [38], as shown in Fig. 1. This comprehensive multi-level framework posited five factors namely, structural, organizational, provider, patient, and innovation level factors that may influence implementation outcomes [38], including routine IPV screening by healthcare providers. Secondly, each of the five themes determined a priori were then sub-categorized into barriers and facilitators to IPV screening during ANC. Thirdly, four transcripts (20% of all transcripts) were read by each of the two coders to identify codes regarding barriers or facilita- tors to IPV screening during ANC. Fourth, consensus was reached on all emergent codes after discussions between the two coders about code names and code definitions. We then collaboratively developed a coding tree. This was conducted using an iterative inductive- deductive thematic approach between coders. Fifth, comparisons of statements were made to identify dif- ferences and similarities between rural and urban- based ANC providers, and provider specialty. Page 5 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 Results Screening practices for IPV As described in Table  1, twenty-two ANC providers were women, six were men while four ANC providers were general physicians, eight assistant nursing officers, and fourteen enrolled midwives. This study identified barriers that affect routine IPV screening and facilitators that improve routine IPV screening in two ANC clinics in rural and urban Uganda. Four emergent themes and quotes that illustrate barriers and facilitators to routine IPV screening are described in Table 2. Out of all twenty- eight healthcare providers, eleven reported conduct- ing routine screening for IPV among women attending ANC clinics, while ten reported having received IPV related training. Among the eleven healthcare provid- ers who conducted routine IPV screening, seven were urban–based ANC providers, while four were based in ANC clinics in rural settings. Among all ten healthcare providers who received IPV related training, only three were rural-based ANC providers compared to seven who were urban-based ANC service providers. One health- care provider acknowledged not routinely screening for IPV and instead relied on women to initiate disclosure as explained by the following excerpt: “We don’t routinely screen for intimate partner vio- lence unless a patient volunteers that information, but we don’t go into it so much.” (#4, M, OBGYN, Urban). Another rural-based provider who also reported not routinely screening for IPV attributed not screening to the lack of special GBV clinics as described below: I: So, do health workers in this clinic routinely screen women for gender-based violence? R: No, unless one has disclosed to you that is when you can talk and help her. I: Are there any other reasons why you think it is not routinely screened for? Fig. 1   Multi-level framework predicting implementation outcomes adapted from Chaudoir and colleagues (2013) Table 1  Participant characteristics and provider screening practices for intimate partner violence in antenatal clinics a General medical practitioner, bObstetrics and Gynaecology Overall, N = 28 Urban, N = 15 Rural, N = 13 Characteristic n n Duration of clinical practice, median (IQR) years 4.0 (0.1–19) 5.0 (1.3–15) 2.0 (0.1–19) Gender   Male 7 3 4   Female 21 12 9 Clinical discipline   Enrolled midwife 14 7 7   Registered midwife 8 5 3   Medical officera 4 1 3   OBGYb 2 2 0 ANC setting   Urban 15 - -   Rural 13 - - Routine IPV screening   No 17 8 9   Yes 11 7 4 IPV training   No 18 8 10   Yes 10 7 3 Page 6 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 R: Maybe because they don’t tell us, or maybe because we do not have a special clinic for that (#11, F, Enrolled Midwife, Rural) Some healthcare providers did not routinely screen for IPV because they assumed that IPV was absent in com- munities as explained in the following excerpt: “We do not ask women about gender-based vio- lence. We assume it is not there in the community and we feel it is not there. That is what we capture in our tool and that is what we forward, but in actual sense we do not ask about gender-based violence when women come for antenatal”. (#12, M, Medical Officer, Rural) However, other healthcare providers reported conduct- ing routine IPV screening during ANC clinics. This practice was exemplified by one rural-based midwife stating that: “It is routine because antenatal is done every day. Remember, when you are registering the moth- ers who have come, you ask, that is when you will have an answer of what to put in the register”. (#1, F, Enrolled midwife, Rural) The emergent themes that describe barriers and facilitators to routine IPV screening in ANC were: 1) Resources; 2) Awareness and training to screen and man- age IPV; 3) Lack of awareness of IPV severity; and 4) Establishing trust (Table 2). Resources Identified resource-related barriers to routine IPV screening included staffing levels, ANC cards without IPV questions, and inadequate space in ANC clinics. However, many healthcare providers overcame these bar- riers through making referrals to specialists, modifying clinic scheduling, counseling IPV survivors, establishing special GBV units, modifying the ANC card to include IPV items and task shifting. Staffing resources  Both rural and urban-based health- care providers reported having limited time to listen to patients. Screening for IPV requires time to build trust- ing relationships in which women are comfortable dis- closing IPV. We need to give these mothers time. When you give a mother time, she will always tell you what is hap- pening to her. So maybe you need to give adequate time to a mother but that may not happen due to high numbers. Sometimes you have so many moth- ers around and of course you have to do something. (#20, F, Enrolled midwife, Urban) If IPV is disclosed, healthcare providers must spend more time counseling women. “We have little time for patients and services are affected in detecting GBV cases because if you are to detect a GBV, you have to take time with this patient talking to her, counseling her, then she will come out. (#7, F, Assistant Nursing Officer, Rural) Sometimes providers give preference to obstetric and fetal wellbeing often viewing psycho-social issues such as IPV as non-medical emergencies. Some healthcare pro- viders also perceived IPV as being potentially non-fatal to the women’s lives as explained in the following excerpt. “Given that we have the time issue, if not being so prominent on the antenatal card, the high vol- Table 2  Emergent themes and sub-themes Emergent themes Sub-themes 1 Resources Staffing shortages Lack of places to refer women facing IPV Availability of GBV screening tools Modification of ANC cards by including IPV items Inadequate physical space 2 Awareness and training Lack of comprehensive IPV training Inadequate IPV screening knowledge Need for brief IPV screening tools 3 Lack of awareness of IPV severity Provider misperceptions 4 Establishing trust Provider initiated probing Rapport building Patient initiated disclosure Page 7 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 ume number, the focus is more on the baby and not maternal complaints. I think even in the training in the obstetric setting that component [gender-based violence] is not so much focused on. We just leave it out. Maybe it is talked about once in a while, but the focus is on those things that kill the mother and kill the baby. That is the focus during antenatal.” (#1, F, Enrolled Midwife, Rural) Because providers may not have adequate time to devote to addressing IPV themselves, they used experts outside ANC clinics such as psychosocial counselors to try to help women living in that situation during IPV screening and follow-up care. Providers stressed the importance of counseling services as being an opportune pathway to identify spousal abuse. This reduces the likelihood of IPV disclosure due to inadequate communication time between providers and patients. In some cases, referrals were made to counselors to screen for IPV and thereaf- ter manage IPV according to screening and management guidelines such as task sharing by referrals to psychoso- cial counsellors as stated below. “The reason is that we have big numbers. Sometimes you are overwhelmed with the numbers. Sometimes you have to involve counselors so instead of spending a lot of time on this mother, yet you are not going to get information, you refer this mother to a counselor because you already have a long queue to work on”. (#19, F, Enrolled Nurse, Urban) Once psychosocial counselors screen and identify IPV, they usually continue to offer survivor support. IPV is a human rights violation. However, some IPV survivors were not aware of that fact. Providers mentioned that psychosocial counseling can aid in raising human rights awareness among IPV survivors attending ANC clinics. The following quote demonstrates this. “The best way is to first counsel those mothers and teach them about their rights then hand them to some organization that handles such matters like women’s organizations. Sometimes we send them to the counselors. We have a good counselor here who works with legal aid. That is what I think is the best option for them”. (#18, M, Medical Officer, Urban) Lack of places to refer women facing IPV  Some ANC service providers stated that they are deterred from rou- tine IPV screening because they do not have knowledge of options to manage and refer IPV survivors. These pro- viders noted how they would rather not screen for IPV without places to refer them. This results in a missed opportunity to detect IPV among ANC attendees as one obstetrician stated: “If you know you are going to screen and find out that she is living in a violent relationship and you know you are going to leave it at that, then I would rather not screen”. (#24, M, OBGYN, Urban) We found that GBV units were located in the HIV clinic only and not in the ANC clinic of the urban-based health facility. Some urban-based participants suggested cre- ating special IPV units within ANC clinics. One urban- based midwife reported that they have a GBV clinic and focal person available within the health facility but that it is not located within the ANC unit. Many different departments make ‘internal’ referrals for GBV manage- ment to this clinic: “When we receive these mothers, and we feel they really need help, we refer them to the gender-based violence department which is based at the ART [anti-retroviral therapy for HIV] clinic…they put them in the GBV corner”. (#6, F, Enrolled Midwife, Urban) Availability of GBV screening tools  GBV screening tools are cues that may prompt clinicians to ask IPV- related questions because it recommends IPV screening for women who present with symptoms of abuse. Health facility-based IPV screening was facilitated by availabil- ity of both ANC registers which have a single yes/no IPV item and GBV incident reporting forms in ANC clinics provided by the Government of Uganda. One obstetri- cian stated that: “We use the ministry of health guidelines to screen and refer and attend to people like that.”. (#24, M, OBGYN, Urban) However, these screening tools are often not utilized because many providers are not aware that such screen- ing tools exist as stated in the following excerpt: “The screening tools are there but they are not known much. I have seen a book of gender-based violence when I was in some health center III. That book [to document IPV] was there though it was not in use, but it was there. Maybe they could increase the SOPs [standard operating procedures], screening tools and even posters because I have seen the ones for family planning and people are well versed with Page 8 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 family planning but not gender based violence”. (#20, F, Enrolled Midwife, Urban) Part of the reason that ANC providers may have been unaware of the screening tool is that they were not located in ANC clinics, but only in the specialized GBV clinics, which were not in every health center. Many providers who were not aware of existing screen- ing tools suggested that the characteristics for these tools should include having ‘few’ IPV items that can be admin- istered quickly so as not to disrupt clinical activities or negatively impact waiting time in ANC clinics. “Not too bulky. If possible, let it take less than five minutes. You ask a few questions to know whether the husband is supportive during this pregnancy that will help her to open up. Some do not open up easily, so you may miss out those mothers but if it is a questionnaire, this will help to identify them very fast. A questionnaire that is specific to things at home, whether the husband is supportive or whether there is violence at home”. (#2, F, Assistant Nursing Officer, Rural) The existing GBV screening tool is brief, only one page long, but as mentioned, providers are not aware of it. Modification of ANC cards by including IPV items  According to some healthcare providers, ANC cards, also called mothers’ passports, do not contain IPV items. Respondents proposed that the current version of ANC cards be modified to include questions probing IPV as a way of facilitating IPV screening during ANC clinic consultations. ANC cards are given to every pregnant women who attends ANC clinics, women keep the ANC cards home and return with them during every scheduled ANC visit. ANC cards are designed to prompt clinicians to elicit women’s medical, social, and family history as well as to document findings from clinical examination. ANC cards are also a way of monitoring women’s preg- nancy and birth plans and to anticipate actions needed in case of complications or risk factors towards mater- nal or fetal health. However, the current version of ANC cards lacks specific items to elicit information about IPV. One provider suggested that including IPV items in ANC cards could act as cues that may increase IPV screening especially during busy clinic days as elaborated in this statement: “We need to come up with something very well organized and we need that information to be put in the mothers’ passport for antenatal. It can help us to ask such whenever you interact with pregnant moth- ers. If it is also included there, we can try to screen each and every mother who comes since we would have where to document [IPV].” (#5, F, Assistant Nursing Officer, Urban) According to one rural-based physician, IPV is usually detected during physical examination, a key opportunity to increase facility-based IPV detection especially dur- ing busy clinic days with a high patient-physician burden. However, ANC cards do not have prompts to elicit IPV as stated in the excerpt below. “The challenge is one, in rural areas, we were being overwhelmed by the number of patients. So, you just follow the assessment of the antenatal card, and antenatal card does not include domestic vio- lence. Gender-based violence, it is not there. So, … normally we discover as I said during examination when you are one on one [with IPV survivors], that is when they can tell you.” (#12, M, Medical Officer, Rural) Inadequate physical space  Another reason for failing to conduct routine IPV screening is the lack of privacy within ANC clinics. Providers highlighted a need for separate rooms in ANC clinics in order to increase con- fidentiality as well as comfort during providers’ interac- tions with women. This suggests that the lack of privacy hinders IPV screening due to the sensitive nature of such issues asked especially during ANC appointment sched- uling. Scheduling occurs during the initial ANC visit where detailed history taking and clinical evaluations are conducted including IPV screening. One midwife reported that IPV screening is not routinely conducted during ANC scheduling because of limited privacy. “When you want to explore issues concerning that [IPV], we need privacy. The best time to explore is the time of booking but the booking is done where there is no privacy”. (#2, F, Assistant Nursing Officer, Rural) Improving clinic infrastructure as a strategy to facilitate IPV screening was proposed by a rural-based ANC mid- wife stating that, “We need to get a private room. When we get a pri- vate room it will work, but unfortunately here our space is too small and the mother will not be willing to tell you in the open because even in the exami- Page 9 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 nation room where we examine mothers there are two beds so there is no one-to-one privacy”. (#14, F, Enrolled Midwife, Rural) Awareness and training to screen and respond to IPV Healthcare providers identified two IPV screening bar- riers related to awareness and training to screen and respond to IPV, namely, lack of comprehensive GBV training and inadequate IPV screening knowledge. Healthcare providers expressed concern that they had not received training in GBV service provision. For example, some healthcare providers stated that many of them had not received any specific GBV training and that their knowledge on IPV screening was obtained mainly during their medical school training as described in this statement: “The challenge is that, personally, it is just because of the knowledge that I attained from school, but I have never gone through gender-based violence training. These workshops I have never. I just use the knowl- edge that I got from school, so we need training, con- tinuous supervision and support”. (#10, M, Enrolled midwife, Rural) A few healthcare providers reported having received IPV training. However, they reported that when only a few people are trained, this reduces the likelihood that those who did not receive training will screen for IPV, let- ting the trained “experts” do it for them. This can serve to reduce screening overall if people who are trained in GBV leave the clinic as described by the participant below. “When you are training [on IPV], it is better to train everyone but then if you just train some groups of people, when they are transferred, they will just go with their knowledge. The ones who remain will not do the work because they will say let those who trained do that work.” (#1, F, Enrolled Midwife, Rural) A lack of IPV training meant that providers were often unsure of how to screen for IPV stating that: “One of the challenges is the knowledge gap. The right way to do the assessment, you may do it because you are a doctor, and you just ask your questions the way you think you should ask them. But is it the right way? So, there is that knowledge gap.” (#9, M, Medi- cal Officer, Rural) Uganda clinical guidelines clearly emphasize the need to screen pregnant women for IPV in ANC clinics. While standardized screening tools for IPV exist in ANC clin- ics, many healthcare providers were unaware of them. They reported that having a standardized tool would help them ask about IPV in the “right way” as stated in the fol- lowing excerpts: “There is no special tool which can help us or one can use to identify someone who is at risk of gender based violence. We surely do not have any tool to help us do the screening. So, it is from our observa- tion that we develop high index of suspicion of gen- der-based violence.” (#16, M, Medical Officer, Rural) “The way we screen, there is no form that will actu- ally guide you in the screening”. (#23, F, Enrolled Midwife, Urban) Lack of awareness of the seriousness of IPV Provider misperceptions  One rural-based physician echoed the practice of not routinely screening for IPV stating that some providers perceive IPV as a ‘home issue’, normalizing violence against women by assuming it does not exist unless the abuse is severe. “We do not normally screen them but when you are carrying out physical examination, that is when they can reveal those secrets. Gender-based violence, those are home issues unless it is severe that they can tell a health worker and that can happen only at the time of examination because we have not reached that level of screening them for gender-based vio- lence”. (#12, M, Medical Officer, Rural) Another provider cited culture being an influence that keeps individuals and communities from disclosing IPV. This excerpt below asserts that beliefs held by communi- ties, including some providers, that ‘outsiders’ should not be told about violence in their homes. “Yes, African culture … There is that saying … that the secrets for the family must remain in the family. They should not be taken to the outsiders, there is that saying.” (#19, F, Enrolled Nurse, Urban) Establishing trust Provider initiated probing  IPV is an emotional expe- rience to survivors and, according to one obstetrician, this makes it uncomfortable for providers to ask and for patients to disclose. Page 10 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 “The fact is that we have not tried so much to dig into intimate partner violence because one, it is not something that people bring up so easily. So, most people find it a little disturbing to start asking”. (#4, M, OBGYN, Urban) One urban based midwife stated that when healthcare workers initiate probing of women for IPV exposure, pri- vacy is needed to develop rapport as described in the fol- lowing quote: “Maybe you try to take that mother from the group [in triage and booking waiting areas], then try to ask and opens up. What is happening? Like are you ok with your husband? What is happening at home? If you try to ask questions, someone will come out and tell you what is happening”. (#5, F, Assistant Nursing Officer, Urban) Providers mentioned asking about IPV during physical exams if signs of abuse are apparent. Even with physical evidence of abuse, it can be difficult for women to open up as described by one rural-based medical doctor in this statement: “They tend to hide the information. Not until you really have the skills of probing, that is when you can get to know that this mother has a GBV problem”. (#16, M, Medical Officer, Rural) In fact, one urban-based provider stated that their prob- ing is occasionally forceful, stating that some mothers are coerced to open up about spousal abuse experienced if they are not willing to open up. “Doctor looked at her and examined her and told her that tell us the truth because I did not believe this story. So, forcing her, she opened up and told us that she was beaten by the husband, the reason being the husband came in with another wife and he forced her to leave the bed and she was beaten seri- ously”. (#3, F, Assistant Nursing Officer, Urban) According to healthcare workers, the signs of physical and emotional IPV may be observable. Visible signs such as low moods suggestive of depression or bodily bruises may indicate potential physical trauma from spousal abuse. Both urban- and rural-based ANC providers described how high levels of IPV suspicion such as pre- screening practices for IPV may increase IPV detection: “From the way they present, this woman will come in with emotional distress which is not okay. So, from your observation and from the training you can assess that this mother is not okay. Sometimes you inquire what could have gone wrong, so that is when you may even know she had the gender- based violence”. (#9, M, Medical Officer, Rural) Rapport building  Healthcare providers play an impor- tant role in GBV prevention and response in Uganda. The quality of patient-physician interactions contributes to trust building, whether clinicians screen for IPV or if pregnant women disclose spousal abuse as one urban- based midwife noted: “According to the relationship or the rapport you have made from the beginning with these mothers, some mothers open up and tell you what is hap- pening at their home, … how the husband is treat- ing her. So, she may tell you that my husband is like this [abusive] …, and normally people put trust in health workers. If you are really a friend, they can tell you everything because they know at times you can help”. (#5, F, Assistant Nursing Officer, Rural) One urban-based midwife explained why it is essential for healthcare providers to establish friendly relation- ships with patients prior to delving into asking women questions that may trigger strong emotions stating that, “I know that as you are going to approach this mother, create a relationship with her because she will never open up to you when you are not her friend. Why? You do not know her and she also does not know you but you want some important information, and when you become a friend, you create a rapport with this mother and she will pour out information”. (#20, F, Enrolled Midwife, Urban) However, the opportunity to establish confidence that abused women have in health care providers is often lim- ited because of the high workload and time constraints facing ANC providers explaining: “After seeing that she has gained some confidence in you [ANC provider]…, she will come out to tell you what the real problem is”. (#7, F, Assistant Nursing Officer, Rural) Patient initiated disclosure  Some participants reported instances of unprompted IPV disclosure by pregnant women in ANC clinics even in the context of non-rou- tine screening for IPV. Patients’ disclosure of abuse per- petrated by their intimate partners before healthcare Page 11 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 providers ask women about IPV was reiterated by one OBGYN as described in the quote below: “There are mothers’ who tell you everything, even before we ask them if they are fine, whether their husbands beat them or slapped them.” (#4, M, OBGYN, Urban) Discussion The purpose of this study was to explore facilitators and barriers to routine screening for IPV by healthcare work- ers in rural and urban-based ANC clinics in Uganda. Our study revealed that many healthcare providers do not routinely screen for IPV in ANC clinics despite exist- ing policy recommendations and clinical guidelines that emphasize the importance of identifying and respond- ing to IPV in healthcare settings [17]. We also identified facilitators and barriers to routine IPV screening in ANC clinics in Uganda. The overarching emergent themes that may explain why some providers screen for IPV while some do not were resource availability, receipt of training in IPV, lack of awareness of IPV severity, and establishing trust. Our findings revealed that many healthcare provid- ers do not routinely screen for IPV among pregnant women attending ANC clinics. This was in line with prior research conducted by Kaye and colleagues which showed that several healthcare workers in an urban refer- ral center in central Uganda neither knew how to, nor routinely screened for domestic violence [41]. Similarly, another study conducted among healthcare workers in Uganda, showed that some healthcare providers did not inquire about IPV exposure at all [42]. In our study, we further ascertained that some clinicians do not rou- tinely screen for IPV because they did not know how to ask about IPV exposure. This may have been because of their lack of awareness of available IPV screening tools which could provide simple ways of asking about IPV. IPV screening also may not have occurred because many clinicians had not received any IPV-related training. Our findings were in line with prior studies conducted in Uganda which showed that some healthcare workers in an urban-based OBGYN unit lacked technical compe- tence to provide optimal ANC care to IPV survivors [41]. Similarly, one study conducted in Uganda by Lawoko and colleagues demonstrated that medical doctors had lower self-efficacy for IPV screening when compared to other healthcare professionals such as midwives [29]. Women in HIC often prefer self-completed [43] or self-report screening tools [44] compared to face-to-face questioning by healthcare providers about spousal abuse. Such self-report tools are not commonly used in Uganda and may not be feasible due to low levels of literacy. Health facility-based screening tools for IPV in Uganda include: (i) GBV incident screening forms containing multiple IPV items [45] and (ii) ANC and family planning registers that have a single IPV item [46]. Although both IPV screening tools are core components of the GBV prevention and response strategy in Uganda [45], our study revealed that some healthcare providers do not ask pregnant women the single, yes/no item in ANC regis- ters. This IPV item in ANC registers lacks corresponding questions which may explain why some providers in our study reported that they did not know how to ask attend- ing women about IPV. Although prior research has questioned use of ‘short’ IPV screening tools due to low validity in measuring IPV [47, 48], some studies found single-item IPV screen- ing tools adequate [49], and valid for clinicians to elicit trauma history [50] as well as reliable in measuring IPV across diverse populations and cultures [51]. It is worth noting that IPV screening among socio-economically disadvantaged and disempowered women has a poten- tial empowering effect on women who are and are not pregnant while also improving confidence and trust in patient-provider relationships [13]. Therefore, we argue that by ensuring that healthcare providers receive train- ing on the use of brief, standardized IPV screening tools, IPV screening in ANC units may improve. Reluctance to routinely screen for IPV or not screen at all can be attributed to work-related pressures aris- ing from the high number of women attending ANC and understaffed ANC clinics. Healthcare workforce shortages remains a persistent and systemic challenge to health service delivery in Uganda. It is noteworthy that the extent of IPV screening is generally low in LMICs [24] including Uganda, when compared to relatively higher initial and repeat IPV screening rates during sub- sequent ANC visits in HICs [33]. Some of the factors that may account for higher rates of health facility-based IPV screening in HICs [52] include: more resources in terms of healthcare staffing and adequate patient-physi- cian interaction time [53]. Since establishing trust often requires time, which is limited in busy ANC clinics, respondents in our study discussed several approaches that can be used to address the high patient-physician ratio in ANC clinics such as increasing provider staff- ing and task sharing. Increasing human resources for health and task sharing are health system strengthen- ing strategies recommended for improved health ser- vice delivery in LMICs [54]. However, current staffing levels are still sub-optimal across the healthcare referral system in Uganda [55], which may contribute to inade- quate routine IPV screening. Despite challenges of high Page 12 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 patient-physician burden and low staffing levels, some providers in our study proposed two innovative mecha- nisms to improve routine IPV screening. First, they rec- ommended creation of special GBV units in rural ANC clinics similar to those in urban healthcare settings in order to complement integrated ANC services aimed at preventing and responding to violence against women and girls. Second, focal persons could be added to the ANC health workforce of focal persons who are specially trained to focus on IPV service provision to perinatal IPV survivors attending ANC clinics. Another resource related constraint to IPV screen- ing was the lack of privacy in ANC units. In our study, healthcare providers who screened for IPV did so in examination rooms. Such rooms have some amount of privacy, which increases providers’ confidence to ask women questions about spousal abuse that are socio-cul- turally sensitive. In line with our findings, a prior health facility-based study conducted in Uganda demonstrated that the lack of an optimum environment, including inadequate privacy, contributes to provision of sub-opti- mal care to IPV survivors during ANC [41]. In line with the Uganda Clinical Guidelines [17], prior research rec- ommends that healthcare workers create opportunities to routinely attend to women privately during ANC [56]. Physician consultations conducted in privacy reduces stress and anxiety which in turn increases chances of IPV disclosure among survivors. Partners’ presence in ANC clinics may deter providers from screening for IPV in cases where providers may suspect retaliatory abuse. Our study revealed more limited resources in rural areas, therefore, addressing space and staff shortages in rural settings should be a priority for strengthening the health- care system which could then improve IPV screening. Our study also found low levels of provider knowl- edge on perinatal IPV and how to screen for it. Several healthcare workers reported that they had not received any training specific to provision of IPV services with rural/urban differences observed. For example, in our study, only three out of ten providers who had received IPV training were rural based. Healthcare providers who had received IPV-related training acknowledged having low awareness on how to screen for IPV suggesting that ANC providers would benefit from comprehensive GBV trainings with emphasis on how to screen for IPV. Prior research in neighboring rural Kenya was in line with our findings demonstrating that healthcare workers lacked training on IPV related issues [57]. Prior studies recom- mend that healthcare worker training on IPV-related issues should place strong emphasis on the different forms of IPV [57], and that the number or duration of IPV trainings should be increased in order to increase the likelihood of recurrent or frequent IPV screening [58]. It is noteworthy that in a study conducted in rural US, while provider IPV knowledge did not predict IPV screening, the duration of IPV training and availability of institutional IPV protocols increased facility-based IPV screening. In addition, IPV training may change provid- ers’ attitudes towards IPV as being a “home matter” as well as may challenge cultural norms that condone IPV. Although some healthcare providers in our study had inadequate or no IPV training, routine IPV screening in ANC clinics was supported by availability of psychoso- cial counselors. Evidence supports the need for specialist domestic abuse clinicians as a useful resource to improve access [59], especially when providers experience chal- lenging IPV survivor cases [60]. We further posit that providing IPV related training to healthcare providers is not enough and should be complemented with struc- tural and system level GBV responses and prevention interventions [22, 61]. For example, trauma-informed care (TIC) are comprehensive, multi-level approaches adopted beyond healthcare facilities, that into account a patients’ life situation in order to realize the widespread impact of trauma, and paths to recovery from trauma [62]. TIC approaches respond by integrating trauma policies and practices in order to improve knowledge and recognition of trauma signs, as well as actively preventing re-traumatization [62]. Integrating TIC into routine clini- cal practice [63] could substantially increase the utility of GBV screening protocols and the subsequent practice of routine IPV screening in ANC clinics. Since most trauma healing can take place outside healthcare settings, trauma informed living environments need to be supported [64]. TIC approaches are survivor-centered and should be pro- vided through creation of safe places, survivor empow- erment, establishment of positive connections between service providers and survivors, and management of the emotional/psychological impact of trauma [65]. Diverse clinical specialties in ANC settings may increase the availability of different clinical skill sets, which aid in clinical decision making in IPV screening and detection if IPV screening tools and protocols are available. Since signs of non-physical IPV are subtle when compared to signs of physical IPV [6], healthcare work- ers may be more observant towards physical injury in women [66], as our study also revealed. Thus, it is impor- tant for providers to be familiar with non-physical forms of abuse in order to holistically probe for IPV in all their patients receiving ANC. Study strengths and limitations We had the following study strengths. First, our study participants had different clinical qualifications and roles in the rural and urban ANC clinics which improves transferability of our findings to similar Page 13 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 contexts. Secondly, data saturation was achieved from interviewing this diverse sample of twenty-eight ANC providers. Thirdly, we used a qualitative methodol- ogy, which are appropriate analytical approaches to explore healthcare providers persepectives on rou- tine screening barriers and facilitators for IPV screen- ing. Finally, credibility of our findings is likely due to member checking that was conducted. This study had some limitations. First, our study had limited diversity in terms of provider views about routine IPV screen- ing in ANC, despite the larger sample of midwives and nurses who are the majority providers of ANC services. Secondly, our study findings may not be transferable to healthcare settings at referral levels other than HCIVs in the study areas. Thirdly, our findings may have been subject to potential response bias due to healthcare providers’ giving socially desirable views based on how they perceived other healthcare providers in the group would respond. Similarly, providers may have had res- ervations about disclosing their IPV screening prac- tices out of anxiety of being blamed or possible punitive actions. Informed consent assured participants of the privacy and confidentiality of their responses. To address potential provider uneasiness, the interviewer took time to build rapport and respond to participant concerns or mistrust. Future research should con- sider triangulating views from a diverse group such as healthcare managers, administrators, or policymakers at different levels whose decisions may directly or indi- rectly impact routine screening in ANC clinics. Actionable points • Increasing the practice of routine IPV screening may be achieved through improving rapport building, encouraging provider-initiated probing, and fostering patient-initiated disclosure. • Health facility-based interventions are warranted to increase routine IPV screening. These include addressing healthcare workforce shortages and health infrastructure challenges to alleviate limited clinic interaction time, inadequate physical spaces to reduce privacy issues and support consult-room and triage-level IPV screening respectively. • Training healthcare workers using trauma-informed care-based approaches and implementation in ANC settings [62, 67] may increase clinicians’ abil- ity to realize the burden of trauma, recognize how all individuals involved with systems, organizations are affected by trauma and respond by putting this knowledge into practice. • Providers posited the need to address safety con- cerns raised by some IPV survivors about retaliatory partner abuse. This highlights a need for safe ANC spaces/environment that encourages IPV disclosure and corresponding appropriate referrals. Conclusions This research was conducted in order to provide key information to support health facility-based GBV responses and prevention efforts including innova- tive approaches to improve IPV screening practices of healthcare providers in ANC clinics. Implementation of initiatives to increase ANC-based IPV screening should focus on addressing resource availability, equitably increasing comprehensive, trauma-informed care based GBV training opportunities, raising awareness of IPV severity among healthcare providers and encouraging the establishment of trusting patient-clinician relation- ships. Advocacy efforts to fill sub-optimal healthcare workforce capacity and infrastructure to address effects of workforce shortages and privacy concerns at health facility level are underscored. Future research should test system-wide, innovative violence prevention and response approaches to increase IPV screening sug- gested by providers in this study. Abbreviations ANC: Antenatal care; CEmONC: Comprehensive Emergency Obstetric and Neonatal Care; GBV: Gender-Based Violence; HCIV: Health Center IV; HIC: High Income Countries; IPV: Intimate Partner Violence; IQR: Inter-Quartile Range; IRB: Institutional Review Board; KCCA​: Kampala Capital City Author‑ ity; LMIC: Low and Middle Income Countries; MCW: Medical College of Wisconsin; MoGLSD: Ministry of Gender, Labor and Social Development; MoH: Ministry of Health; OBGYN: Obstetricians / Gynecologists; TASO: The AIDS Support Organization; UCG​: Uganda Clinical Guidelines; UNCST: Uganda National Council of Science and Technology; WHO: World Health Organization. Supplementary Information The online version contains supplementary material available at https://​doi.​ org/​10.​1186/​s12913-​022-​07669-0. Additional file 1.  Acknowledgements Appreciation goes to Mr. Ronald Tenywa for transcribing the audio recordings. Authors’ contributions All authors (RA, LDC, HB, KMMB, RJW, JDG) made substantial contributions to the conception and design of this research. RA conducted all the interviews. RA and JDG were involved in the coding, and analysis of the interview data. and conducted the analysis. All authors (RA, LDC, HB, KMMB, RJW, JDG) were involved in interpretation the interview data. All authors (RA, LDC, HB, KMMB, RJW, JDG) made major contributions in writing the manuscript, providing feedback on drafts throughout the writing process. All authors read and approved the final manuscript. https://doi.org/10.1186/s12913-022-07669-0 https://doi.org/10.1186/s12913-022-07669-0 Page 14 of 15Anguzu et al. BMC Health Services Research (2022) 22:283 Funding The authors declare no funding with respect to the research or publication of this article. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate Ethical approval to conduct this study was received from the Medical College of Wisconsin (MCW) Institutional Review Board (IRB) Ref: PRO00036397 and The AIDS Support Organization (TASO) IRB Ref: TASOREC/083/19-UG-REC-009 respectively. National clearance was obtained from the Uganda National Council of Science and Technology (UNCST) Ref. SS 5243. Administrative per‑ mission was also obtained from the Directorate of Public and Environmental Health at KCCA and the District Health Officer of Luuka district. This research was performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all respondents. Privacy and confidenti‑ ality of collected data was upheld. Consent for publication Not applicable. Competing interests The authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article. Author details 1 Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, Wisconsin, USA. 2 Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Makerere University College of Health Sciences, New Mulago Gate Road, Mulago, Kampala, Uganda. 3 Department of Child Health and Development Center, School of Medicine, Makerere University, College of Health Sciences, Mulago Hill, Hospital Complex, P.O. Box 7072, Kampala, Kampala, Uganda. 4 Center for Advancing Population Sci‑ ences (CAPS), Medical College of Wisconsin, Milwaukee, Wisconsin, USA. 5 Divi‑ sion of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA. Received: 19 July 2021 Accepted: 21 February 2022 References 1. Basile KC, Hertz MF, Black SE. Intimate partner violence and sexual vio‑ lence victimization assessment instruments for use in healthcare settings. 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Children. 2021;8(11):1061. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub‑ lished maps and institutional affiliations. Facilitators and barriers to routine intimate partner violence screening in antenatal care settings in Uganda Abstract Background: Methods: Results: Conclusions: Background Methods Study design and setting Sample and recruitment Data collection procedure In-depth interview guide Qualitative data analysis Results Screening practices for IPV Resources Awareness and training to screen and respond to IPV Lack of awareness of the seriousness of IPV Establishing trust Discussion Study strengths and limitations Actionable points Conclusions Acknowledgements References