Tenders are invited for Consultancy for Mixed-Methods Study on Gynecological and Obstetric Violence Consultancy Mixed-Methods Study on Gynecological and Obstetric Violence in Antananarivo TERMS OF REFERENCE FOR THE IMPLEMENTATION OF A MIXED-METHODS STUDY ON GYNECOLOGICAL AND OBSTETRIC VIOLENCE IN ANTANANARIVO 1. CONTEXT 1.1 ORIGIN OF THE REQUEST Gynecological and obstetric violence (GOV) refers to all acts, omissions, behaviors, or practices occurring within the framework of sexual and reproductive health (SRH) care that undermine the dignity, physical or psychological integrity, autonomy, or rights of women and transgender men. They can take various forms, including physical violence, care performed without free and informed consent, breaches of confidentiality, psychological violence (humiliating or discriminatory behavior), refusal or abandonment of care, sexual violence, as well as certain institutional practices limiting patients rights. Over the past decade, GOV has received increasing attention from international organizations. The World Health Organization (WHO) recognizes that many women worldwide experience mistreatment during childbirth in health facilities. These practices constitute not only a violation of womens fundamental rights but also an obstacle to improving maternal and neonatal health. The WHO emphasizes that every woman has the right to respectful care that preserves her dignity, confidentiality, autonomy, and informed consent. Beyond the childbirth period, UNFPA and several international bodies now place GOV within a broader reflection on reproductive violence, defined as any attack on reproductive autonomy and womens ability to make free decisions regarding their SRH. This also includes the non-assessment and non-management of pain. This approach helps highlight the links between GOV, gender inequalities, and other forms of gender-based violence (GBV). The consequences of GOV are multiple. They can lead to lasting physical and psychological trauma, a loss of trust in health professionals, and a decrease in seeking care. Indeed, several studies have shown that the experience of violence or mistreatment during childbirth or a gynecological consultation can deter women from returning to health facilities for subsequent care, thereby compromising efforts to reduce maternal mortality and morbidity. In Madagascar, socio-cultural norms limit womens autonomy in making decisions about their own health, and they are often dependent on the decisions of their husband and/or family. The lack of education on sexual and reproductive health issues also leaves many women poorly informed about their rights and available services. This is despite the framework of the National Reproductive Health Policy (PNSR) and the National Policy for the Fight against Gender-Based Violence, which recognize womens right to respectful care but whose implementation remains insufficient in practice. In health facilities, although progress has been made to improve care, violent and disrespectful practices towards pregnant women persist. This is explained particularly by the lack of financial resources and staff shortages. This lack of resources translates, among other things, into a lack of awareness and training for health professionals in respectful maternity care and patients rights. It is also fostered by the normalization, or even denial, of certain practices of gynecological and obstetric violence, which are sometimes still considered normal within healthcare structures. In Madagascar, the literature on gynecological and obstetric violence remains extremely limited. Only one qualitative study identified to date has explicitly documented obstetric violence in three rural regions of the country. Its results highlight several forms of mistreatment, including lack of information and consent, communication failures, breaches of privacy, verbal humiliation, discrimination linked to socio-economic status, as well as certain unexpected costs of care. The study also emphasizes that tensions between local cultural practices and biomedical requirements can foster stigmatizing behaviors towards women. Finally, the authors show that the observed violence occurs within a context marked by significant structural constraints, such as lack of staff, equipment, and resources, likely to alter the quality of care and reduce the use of maternal health services. Although not directly addressing the concept of GOV, several anthropological studies conducted in Madagascar had already highlighted asymmetrical power relations, situations of negligence, and negative experiences lived by women within reproductive health services. Other available work indirectly addresses certain dimensions of GOV through the quality of maternal care, caregiver-patient relationships, or gender-based violence. In this context, carrying out a mixed-methods study on GOV appears essential to document the phenomenon, better understand the experiences of women and health professionals, and contribute to strengthening policies and practices promoting respectful, person-centered care based on human rights. The results of this study in the Malagasy urban context may serve as a basis for future research in other regions of the country. 1.2 BRIEF PRESENTATION OF THE PROJECTS DSF is currently implementing two projects: The MIRA project: "Towards multidisciplinary and ethical care for womens health", whose overall objective is to significantly improve womens healthcare in Antananarivo by strengthening the quality, accessibility, and humanization of care while actively combating gynecological and obstetric violence. Funded by the French Embassy, this project will end in September 2027. The specific objectives of the project are as follows: SO 1: Improve the quality and sustainability of the healthcare offer proposed to pregnant women and/or those suffering from painful gynecological pathologies through the following activities: Train & support health personnel Equip and rehabilitate health facilities Provide medical and psychological home care Carry out integrated awareness, prevention, and screening campaigns in womens health SO 2: Contribute to strengthening national strategies aimed at combating gender-based violence, including gynecological and obstetric violence, through the following activities: Inform, educate, and communicate about gynecological and obstetric violence Strengthen institutional advocacy and coordination between actors This project is part of a dynamic of systemic change, aiming to ensure that every Malagasy woman can access health services that are adapted, respectful of her rights, and meet her specific needs. The project supports existing health facilities in Antananarivo city by strengthening the capacity of healthcare personnel on various themes such as the humanization of care, management of gynecological pathologies, and psychological first aid management. These training/orientation sessions will raise awareness among caregivers about the specific needs of women, thus contributing to a notable improvement in the quality of care. In parallel, the project deploys a vast advocacy and awareness campaign to combat GBV/GOV, informing Malagasy society of the dangers of this violence and mobilizing key actors for lasting change. It is through this project that the present study will be funded. The VITA CCU project, "Womens Rights and Health for the Screening and Management of Cervical Cancer (CCU) in Madagascar" aims to reduce morbidity and mortality related to CCU among women aged 25 to 49, particularly sex workers (SW), in Antananarivo and Mahajanga. Funded by Expertise France and led by Médecins du Monde France, in partnership with AFSA and Douleurs Sans Frontières (DSF), the project began in June 2025 and spans 36 months. This project is structured around 3 specific objectives: SO1: Improve CCU screening and management by strengthening the capacities of health facilities (CSB, CHRD, CHU) through the following activities: Train healthcare personnel on the prevention, screening, and treatment of precancerous and cancerous lesions of the CCU, Ensure the availability of inputs and equipment, Implement mentorships and joint supervisions with health authorities. SO2: Strengthen the role of community actors in the fight against CCU in Tana and Mahajanga (awareness, prevention, management) through the following activities: Train AFSA peer educators on HPV self-sampling, Raise awareness among sex workers about their rights and health and encourage seeking care, Implement an HPV sample collection system for transport to the reference lab, Set up a home care system for palliative and end-of-life care, Carry out mass awareness campaigns on SRHR and CCU. SO3: Promote a societal, political, and legal environment favorable to the fight against CCU and sexual and reproductive health and rights (SRHR) through the following activities: Carry out a feasibility and operationalization study for the implementation of the fight against CCU, Better management of early and reliable screening for female cancers, access to care and treatment including palliative care for women with cancer, Implement advocacy for the integration of HPV testing and vaccination, self-sampling practice, and thermo-coagulation into government funding, etc. Support the implementation of a national strategy to combat GOV within partner health facilities. In this context, the prevention of and fight against GOV constitute a cross-cutting component of these two projects. This study aims to produce original data on the manifestations, frequency, and determinants of GOV in health facilities in Antananarivo to guide public policies, training strategies for health professionals, and advocacy actions. The GOV study will be entrusted to an external consultant who will be resp Tender Link : https://www.coordinationsud.org/appels-doffres/?_localisations=afrique%2Casie%2Cmoyen-orient
