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Background In most countries, reliable national statistics on femicide, intimate partner femicide (IPF), and non-intimate partner femicide (NIPF) are not available. Surveys are required to collect robust data on this most extreme consequence of intimate partner violence (IPV). We analysed 3 national surveys to compare femicide, IPF, and NIPF from 1999 to 2017 using age-standardised rates (ASRs) and incidence rate ratios (IRRs). Methods and findings We conducted 3 national mortuary-based retrospective surveys using weighted cluster designs from proportionate random samples of medicolegal laboratories. We included females 14 years and older who were identified as having been murdered in South Africa in 1999 (n = 3,793), 2009 (n = 2,363), and 2017 (n = 2,407). Further information on the murdered cases were collected from crime dockets during interviews with police investigating officers. Our findings show that South Africa had an IPF rate of 4.9/100,000 female population in 2017. All forms of femicide among women 14 years and older declined from 1999 to 2017. For IPF, the ASR was 9.5/100,000 in 1999. Between 1999 and 2009, the decline for NIPF was greater than for IPF (IRR for NIPF 0.47 (95% confidence interval (CI) 0.42 to 0.53) compared to IRR for IPF 0.69 (95% CI 0.63 to 0.77). Rates declined from 2009 to 2017 and did not differ by femicide type. The decline in IPF was initially larger for women aged 14 to 29, and after 2009, it was more pronounced for those aged 30 to 44 years. Study limitations include missing data from the police and having to use imputation to account for missing perpetrator data. Conclusions In this study, we observed a reduction in femicide overall and different patterns of change in IPF compared to NIPF. The explanation for the reductions may be due to social and policy interventions aimed at reducing IPV overall, coupled with increased social and economic stability. Our study shows that gender-based violence is preventable even in high-prevalence settings, and evidence-based prevention efforts must be intensified globally. We also show the value of dedicated surveys in the absence of functional information systems., Author(s): Naeemah Abrahams 1,2,*, Shibe Mhlongo 1, Esnat Chirwa 1,3, Bianca Dekel 1,4, Asiphe Ketelo 1, Carl Lombard 5,6, Nwabisa Shai 1, Leane Ramsoomar 1, Shanaaz Mathews 7, Gérard Labuschagne [...]

We describe 131 South African sexual assault survivors offered HIV post-exposure prophylaxis (PEP). While the median days completed was 27 (IQR 27, 28), 34% stopped PEP or missed doses. Controlling for baseline symptoms, PEP was not associated with symptoms (OR = 1.30, 95% CI = 0.66, 2.64). Factors associated with unprotected sex included prior unprotected sex (OR = 6.46, 95% CI = 3.04, 13.74), time since the assault (OR = 1.33, 95% CI = 1.12, 1.57) and age (OR = 1.30, 95% CI = 1.08, 1.57). Trauma counseling was protective (OR = 0.18, 95% CI = 0.05, 0.58). Four instances of seroconversion were observed by 6 months (risk = 3.7%, 95% CI = 1.0, 9.1). Proactive follow-up is necessary to increase the likelihood of PEP completion and address the mental health and HIV risk needs of survivors. Adherence interventions and targeted risk reduction counseling should be provided to minimize HIV acquisition.

The purpose of this study was to characterize healthcare use for general care and mental health one year before suicidal behavior among individuals with fatal and non-fatal suicidal behavior (NFSB) in Cape Town, South Africa. We linked electronic health records of 484 participants from a case series of 93 completed suicides on whom forensic autopsies were performed at a mortuary in Cape Town, between August 2014 and January 2016; and 391 patients admitted to hospital following NFSB between June 2014 and March 2015, and between August 2015 and August 2017. Time from last healthcare visit to date of suicidal behavior (fatal or non-fatal) was calculated, and Kaplan Meier curves were used to compare the differences by psychiatric diagnoses and study group. Overall, 64.5% of completed suicides and 65.9% of NFSB patients sought general healthcare in the year before suicidal behavior. Most of these visits occurred at hospital outpatient clinics (40.8%) and primary healthcare facilities (31.3%). The prevalence of preexisting psychiatric diagnoses and the use of mental healthcare services was lower for individuals who completed suicide compared to NFSB patients. Common reasons for a healthcare visit among individuals who completed suicide were chronic disease and assault; and psychiatric illness (depression, bipolar, and/or substance use disorders), chronic disease and HIV among NFSB patients. A large proportion of individuals with fatal and NFSB interacted with the healthcare system before suicidal behavior. These findings suggest opportunities for suicide prevention at primary healthcare facilities, antiretroviral treatment centers and emergency departments. Healthcare access is common among individuals with fatal and NFSB in the year before suicidal behavior. The prevalence of mental disorder diagnoses is higher among NFSB patients than among individuals who completed suicide. A greater proportion of NFSB patients accessed mental healthcare services compared to individuals who completed suicide. [ABSTRACT FROM AUTHOR]

Objective To describe age- and sex-specific rates of child homicide in South Africa. Methods A cross sectional mortuary-based study was conducted in a national sample of 38 medicolegal laboratories operating in 2009. These were sampled in inverse proportion to the number that were operational in each of three strata defined by autopsy volume: 1499 annual autopsies. Child homicide data were collected from mortuary files, autopsy reports and police interviews. Cause of death, evidence of abuse and neglect or of sexual assault, perpetrator characteristics and circumstances surrounding the death were investigated. Findings An estimated 1018 (95% confidence interval, CI: 843-1187) child homicides occurred in 2009, for a rate of 5.5 (95% CI: 4.6-6.4) homicides per 100 000 children younger than 18 years. The homicide rate was much higher in boys (6.9 per 100 000; 95% CI: 5.6-8.3) than in girls (3.9 per 100 000; 95% CI: 3.2-4.7). Child abuse and neglect had preceded nearly half (44.5%) of all homicides, but three times more often among girls than among boys. In children aged 15 to 17 years, the homicide rate among boys (21.7 per 100 000; 95% CI: 14.2-29.2) was nearly five times higher than the homicide rate among girls (4.6 per 100 000; 95% CI: 2.4-6.8). Conclusion South Africa's child homicide rate is more than twice the global estimate. Since a background of child abuse and neglect is common, improvement of parenting skills should be part of primary prevention efforts. Objectif Detailler les taux d'homicide d'enfants en Afrique du Sud par age et par sexe. Methodes Une etude transversale basee sur les autopsies a ete menee sur un echantillon national de 38 laboratoires medico-legaux en 2009. Ces laboratoires ont ete choisis en proportion inverse du nombre de laboratoires qui etaient operationnels dans chacune des trois strates definies par le nombre d'autopsies realisees par an: 1499. Les donnees sur les homicides d'enfants ont ete cotlectees a partir des fichiers mortuaires, des rapports d'autopsie et des interrogatoires de police. La cause de la mort, la preuve de l'abus, de la negligence ou de l'agression, les caracteristiques des agresseurs sexuels, et les circonstances entourant le deces ont ete etudiees. Resultats On estime que 1018 (intervalle de confiance de 95%: 843 a 1187) homicides d'enfants ont eu lieu en 2009, pour un taux de 5,5 (IC de 95%: 4,6 a 6,4) homicides pour 100 000 enfants de moins de 18 ans. Le taux d'homicide etait beaucoup plus eleve chez les garcons (6,9 pour 100 000, IC de 95%: 5,6 a 8,3) que chez les filles (3,9 pour 100 000, IC de 95%: 3,2 a 4,7). La maltraitance et la negligence des enfants etaient a l'origine de pres de la moitie (44,5%) des homicides, mais cela trois fois plus souvent chez les filles que chez les garcons. Chez les enfants ages de 15 a 17 ans, le taux d'homicides chez les garcons (21,7 pour 100 000; IC de 95%: 14,2 a 29,2) etait pres de cinq fois plus eleve que le taux d'homicide chez les filles (4,6 pour 100 000, IC de 9.5%: 2,4 a 6.8). Conclusion Le taux d'homicide d'enfants en Afrique du Sud est deux fois plus eleve que la moyenne mondiale estimee. Puisqu'on retrouve frequemment un climat de violence et de negligence envers les enfants, l'amelioration des competences parentales devrait faire partie des principaux efforts de prevention. Objetivo Describir las tasas especificas por edad y sexo de los homicidios de menores en Sudafrica. Metodos Se realizo un estudio transversal basado en datos de los depositos de cadaveres en una muestra nacional de 38 laboratorios medico-legales activos en 2009. Se muestrearon en proporcion inversa al numero que estaba operativo en cada uno de los tres estratos definidos por volumen de autopsias: 1499 autopsias anuales. Los datos de los homicidios de menores se recopilaron de los archivos de los depositos de cadaveres, de informes de autopsias y de entrevistas con la policia. Se investigaron la causa del fallecimiento, las pruebas de abuso y abandono o de agresion sexual, las caracteristicas del homicida y las circunstancias aledanas al fallecimiento. Resultados En concepto de estimacion, en 2009 se perpetraron 1018 (intervalo de confianza 95%: 843-1187) homicidios de menores, lo que representa una tasa de 5,5 (intervalo de confianza 95%: 4,6-6,4) homicidios por cada 100 000 menores de 18 anos. La tasa de homicidios era mucho mas alta en ninos (6,9 por cada 100 000; intervalo de confianza 95%: 5,6-8,3) que en ninas (3,9 por cada 100 000; intervalo de confianza 95%: 3,2-4,7). El abuso y abandono de los menores habia precedido a casi la mitad (44,5%) de todos los homicidios, si bien fue tres veces mas frecuente entre las ninas que entre los ninos. En menores de 15 a 17 anos, la tasa de homicidios masculina (21,7 por cada 100 000; intervalo de confianza 95% 14,2-29,2) fue casi cinco veces mayor que la femenina (4,6 por cada 100 000; intervalo de confianza 95%: 2,4-6,8). Conclusion La tasa de homicidios de menores de Sudafrica es mas del doble que la estimacion global. Como los precedentes de abuso y abandono de los menores son habituales, la mejora de las competencias de los padres deberia formar parte de los primeros esfuerzos de prevencion., Introduction Thousands of children are victims of homicide annually, despite the right to protection and care afforded under the United Nations Convention on the Rights of the Child. (1) Child [...]

The purpose of this article is to describe mortality of women from intimate partner violence (IPV) in South Africa using a retrospective national study in a proportionate random sample of 25 mortuaries. Homicides identified from mortuary, autopsy, and police records. There were 3,797 female homicides, of which 50.3% were from IPV. The mortality rate from IPV was 8.8 per 100,000 women. Mortality from IPV were elevated among those 14 to 44 years and women of color. Blunt force injuries were more common, while strangulation or asphyxiation were less common. The national IPV mortality rate was more than twice that found in the United States. The study highlights the value of collecting reliable data across the globe to develop interventions for advocacy of which gender equity is critical. Keywords: female homicide; femicide; intimate partner violence; South Africa

Objective: Levels of alcohol use are high in South Africa and not much is known about women's use of alcohol when murdered. The aim of this article is to describe the patterns of blood alcohol concentration (BAC) at the time of death for female homicide victims and to explore the factors associated with having an elevated BAC. Method: A subsample of a national, representative, retrospective mortuary-based study of female homicides ages 14 years and older was analyzed. Data were gathered from medical legal laboratory records, autopsy reports, and police interviews from 153 cases at sampled mortuaries in the Western Cape Province of South Africa in 1999. Results: Sixty-two percent of women who were murdered had a high BAC at the time of their death, with an overall median BAC of. 11% (110 mg/100 ml). A quantile regression analysis showed that a raised median BAC at the time of death was positively associated with the victim's age; being unemployed or not known to be employed; and being killed in a rural setting, in a public space, and on a weekend. Significant interactions between type of homicide and employment showed a modification in median BACs for unemployed victims killed by intimate partners compared with employed victims, with a median difference of. 19% (190 mg/100 ml) (95% confidence interval: .14%-.23% [140-230 mg/100 ml]). Conclusions: This study highlights the public health impact of excessive alcohol consumption and the need for a comprehensive approach to reduce the harmful effects of drinking., THE RELATIONSHIP BETWEEN ALCOHOL and interpersonal violence is well established (Room et al., 2005). Alcohol consumption increases men's risk of violence perpetration and men and women's risk of becoming a [...]

Objective To examine the incidence and patterns of intimate femicide-suicide in South Africa and to describe the factors associated with an increase in the risk of suicide after intimate femicide (i.e. the killing of an intimate female partner). Methods A cross-sectional retrospective national mortuary-based study was conducted at a proportionate random sample of 25 legal laboratories to identify all homicides committed in 1999 of women aged over 13 years. Data were collected from the mortuary file, autopsy report and a police interview. Findings Among 1349 perpetrators of intimate femicide, 19.4% committed suicide within a week of the murder. Suicide after intimate femicide was more likely if the perpetrator was from a white rather than an African racial background (odds ratio, OR: 5.8; 95% confidence interval, CI: 1.21-27.84); was employed as a professional or white-collar worker rather than a blue-collar worker (OR: 37.28; 95% CI: 5.82-238.93); and owned a legal gun rather than not owning a legal gun (OR: 45.26; 95% CI: 8.33-245.8). The attributable fraction shows that 91.5% of the deaths of legal gun-owning perpetrators and their victims may have been averted if this group of perpetrators did not own a legal gun. Conclusion South Africa has a rate of intimate femicide-suicide that exceeds reported rates for other countries. This study highlights the public health impact of legal gun ownership in cases of intimate femicide-suicide. Objectif Examiner l'incidence et les schemas du femicide-suicide intime en Afrique du Sud et decrire les facteurs associes a une augmentation du risque de suicide apres un femicide intime (c'esta-dire le meurtre d'un partenaire feminin intime). Methodes Une etude retrospective transversale nationale a partir d'autopsies a ete menee dans un echantillon aleatoire proportionne de 25 laboratoires de medecine legale pour identifier tous les homicides commis en 1999 sur des femmes de plus de 13 ans. Les donnees ont ete recueillies a partir des dossiers mortuaires, ales rapports d'autopsie et des interrogatoires de police. Resultats Parmi 1349 auteurs de femicide intime, 19,4 % s'etaient suicides dans la semaine suivant le meurtre. Apres un femicide intime, la probabilite de suicide etait plus grande si l'auteur etait de race blanche plutot que d'origine africaine (odds ratio, OR: 5,8 ; intervalle de confiance, IC a 95 % : 1,21-27,84), exercait une profession liberale ou etait employe plutot qu'ouvrier (OR : 37,28 ; IC a 95 % : 5,82-238,93) et detenait Iegalement une arme a feu (OR: 45,26; IC a 95 %: 8,33-245,8). D'apres la fraction attribuable, 91,5 % des deces des detenteurs legaux d'arme a feux et de leurs victimes auraient pu etre evites si les meurtriers n'avaient pas detenu une telle arme. Conclusion L'Afrique du Sud presente un taux de femicide-suicide intime qui depasse les taux rapportes pour les autres pays. Cette etude met en lumiere l'impact en termes de sante publique de la detention legale d'armes a feu dans les cas de femicide-suicide intime. Objetivo Examinar la incidencia y las modalidades del feminicidio-suicidio de parejas en Sudafrica y describir los factores asociados al aumento del riesgo de suicidio tras el feminicidio de pareja (es decir, el asesinato de la mujer con la que se mantiene una relacion intima). Metodos Se realizo un estudio retrospectivo transversal nacional basado en depositos de cadaveres en una muestra aleatoria proporcional de 25 laboratorios forenses a fin de identificar todos los asesinatos de mujeres de mas de 13 anos cometidos en 1999. Los datos analizados proceden de los registros de las morgues, de los informes de autopsia y de entrevistas con la policia. Resultados De los 1349 feminicidas de su pareja, el 19,4% se suicidaron durante la semana siguiente al asesinato. El suicidio posterior al feminicidio de pareja era mas probable cuando el autor era de raza blanca, por oposicion a las personas de origen africano (razon de posibilidades, OR: 5,8; intervalo de confianza (IC) del 95%: 1,21-27,84); tenia un empleo como profesional u oficinista en lugar de como trabajador manual (OR: 37,28; IC95%: 5,82-238,93); o estaba en posesion legal de un arma de fuego (OR: 45,26; IC95%: 8,33-245,8, en comparacion con las personas sin arma). La fraccion atribuible muestra que un 91,5% de las muertes de los asesinos en posesion legal de un arma de fuego y de sus victimas podria haberse evitado si hubiesen carecido de arma. Conclusion Sudafrica presenta una tasa de feminicidio-suicidio de parejas superior a las de otros paises. Este estudio porte de relieve el impacto para la salud publica de la tenencia legal de armas de fuego en los casos de feminicidio-suicidio de parejas., Introduction Intimate femicide, the killing of a woman by her intimate partner, is considered the most extreme form and consequence of intimate partner violence. Until recently, not much has been [...]

Objective To investigate in the South African public health sector where the best services for rape survivors were provided, who provided them, what the providers' attitudes were towards women who had been raped and whether there were problems in delivering care for rape survivors. Methods A cross-sectional study of facilities was carried out. Two district hospitals, a regional hospital and a tertiary hospital (where available) were randomly sampled in each of the nine provinces in South Africa. At each hospital, senior staff identified two doctors and two nurses who regularly provided care for women who had been raped. These doctors and nurses were interviewed using a questionnaire with both open-ended and closed questions. We interviewed 124 providers in 31 hospitals. A checklist that indicated what facilities were available for rape survivors was also completed for each hospital. Findings A total of 32.6% of health workers in hospitals did not consider rape to be a serious medical condition. The mean number of rape survivors seen in the previous six months at each hospital was 27.9 (range = 9.3-46.5). A total of 30.3% of providers had received training in caring for tape survivors. More than three-quarters of regional hospitals (76.9%) had a private exam room designated for use in caring for rape survivors. Multiple regression analysis of practitioner factors associated with better quality of clinical care found these to be a practitioner being older than 40 years (parameter estimate = 2.4; 95% confidence interval (CI) = 0.7-5), having cared for a higher number of rape survivors before (parameter estimate = 0.02; 95% CI = 0.001-0.03), working in a facility that had a clinical management protocol for caring for rape survivors (parameter estimate = 2; 95% CI = 0.12-3.94), having worked for less time in the facility (parameter estimate = -0.2; 95% CI = -0.3 to -0.04) and perceiving rape to be a serious medical problem (parameter estimate = 2.8; 95% CI=1.9-3.8). Conclusion There are many weaknesses in services for rape survivors in South Africa. Our findings suggest that care can be improved by disseminating clinical management guidelines and ensuring that care is provided by motivated providers who are designated to care for survivors. Keywords Rape/rehabilitation; Health services; Quality of health care; Attitude of health personnel; Forensic medicine; Health care surveys; Cross-sectional studies; South Africa (source: MeSH, NLM). Mots cles Viol/reeducation & readaptation; Services sante; Qualite soins; Attitude du personnel soignant; Medecine legale; Enquete systeme de sante; Etude section efficace; Afrique du Sud (source: MeSH, INSERM). Palabras clave Violacion/rehabilitacion; Servicios de salud; Calidad de la atencion de salud; Actitud del personal de salud; Medicina legal; Encuestas de atencion de la salud; Estudios transversales; Sudafrica (fuente: DeCS, BIREME). Bulletin of the World Health Organization 2005;83:495-502., Introduction Rape is an important public health and human rights concern. Its consequences include unwanted pregnancy, unsafe abortion, genital fistulae, pelvic inflammatory disease, sexually transmitted infections such as HIV/AIDS, depression, [...]

Background Homicide of children is a global problem. The under-5-y age group is the second largest homicide age group after 15-19 y olds, but has received little research attention. Understanding age and gender patterns is important for assisting with developing prevention interventions. Here we present an age and gender analysis of homicides among children under 5 y in South Africa from a national study that included a focus on neonaticide and infanticide. Methods and Findings A retrospective national cross-sectional study was conducted using a random sample of 38 medico-legal laboratories operating in 2009 to identify homicides of children under 5 y. Child data were abstracted from the mortuary files and autopsy reports, and both child and perpetrator data data were collected from police interviews. We erred towards applying a conservative definition of homicide and excluded sudden infant death syndrome cases. We estimated that 454 (95% CI 366, 541) children under the age of 5 y were killed in South Africa in 2009. More than half (53.2%; 95% CI 46.7%, 59.5%) were neonates (0-28 d), and 74.4% (95% CI 69.3%, 78.9%) were infants (under 1 y), giving a neonaticide rate of 19.6 per 100,000 live births and an infanticide rate of 28.4 per 100,000 live births. The majority of the neonates died in the early neonatal period (0-6 d), and abandonment accounted for 84.9% (95% CI 81.5%, 87.8%) of all the neonates killed. Distinct age and gender patterns were found, with significantly fewer boy children killed in rural settings compared to urban settings (odds ratio 0.6; 95% CI 0.4, 0.9; p = 0.015). Abuse-related killings and evidence of sexual assault were more common among older girls than in all other age and gender groups. Mothers were identified as the perpetrators in all of the neonaticides and were the most common perpetrators overall (71.0%; 95% CI 63.9%, 77.2%). Abandoned neonates were mainly term babies, with a mean gestational age of 38 wk. We did not have information on abandonment motives for all newborns and did not know if babies were abandoned with the intention that they would die or with the hope that they would be found alive. We therefore considered all abandoned babies as homicides. Conclusions Homicide of children is an extreme form or consequence of violence against children. This national study provides one of the first analyses of neonaticide and infanticide by age and gender and shows the failure of reproductive and mental health and social services to identify and help vulnerable mothers. Multi-sectoral prevention strategies are needed., Author(s): Naeemah Abrahams 1,*, Shanaaz Mathews 2, Lorna J. Martin 3,4, Carl Lombard 5, Nadine Nannan 6, Rachel Jewkes 1 Introduction The number of children killed in a country is [...]

Background: Death is the most extreme consequence of intimate partner violence. Female homicide studies with data on the perpetrator-victim relationship can provide insights. We compare the results of two South African national studies of female homicide with similar sampling done 10 y apart. Methods and Findings: We conducted a retrospective national survey using a weighted cluster design of a proportionate random sample of 38 mortuaries to identify homicides committed in 2009. We abstracted victim data from mortuary and autopsy reports, and perpetrator data from police interviews. We compared homicides of women 14 y and older in 2009 with previously published data collected with the same methodology for homicides committed in 1999. The study found that the rate of female homicide per 100,000 female population in 2009 was 12.9 (95% confidence interval [CI]: 9.3, 16.5), compared to 24.7 (95% CI: 17.7, 31.6) in 1999. The incidence rate ratio of 0.54 (95% CI: 0.20, 0.84) reflects a significantly lower rate in 2009. The rate of intimate partner femicide was 5.6/100,000 in 2009 versus 8.8/100,000 in 1999, with an incidence rate ratio of 0.63 (95% CI: 0.24, 1.02), indicating no difference between rates. Logistic regression analysis of homicide characteristics showed that the odds ratio of suspected rape among non-intimate femicides in 2009 compared to 1999 was 2.61 (95% CI: 1.23, 4.08) and among intimate partner femicides it was 0.84 (95% CI: 0.50, 1.42). The OR of homicide by gunshot was 0.54 (95% CI: 0.30, 0.99) in 2009 versus 1999. There was a significant drop in convictions of perpetrators of nonintimate femicide in 2009 versus 1999 (OR = 0.32 [95% CI: 0.19, 0.53]). Limitations of the study include the relatively small sample size and having only two time points. Conclusions: Female homicide in South Africa was lower in 2009 than 1999, but intimate partner femicide and suspected rape homicide rates were not statistically different. The cause of the difference is unknown. The findings suggest that South Africa needs greater efforts nationally to implement evidence-based violence prevention., Introduction The murder of an intimate partner is one of the most extreme consequences of gender-based violence. Although intimate partner violence (IPV) can be perpetrated by both males and females, [...]

Objective To investigate in the South African public health sector where the best services for rape survivors were provided, who provided them, what the providers' attitudes were towards women who had been raped and whether there were problems in delivering care for rape survivors. Methods A cross-sectional study of facilities was carried out. Two district hospitals, a regional hospital and a tertiary hospital (where available) were randomly sampled in each of the nine provinces in South Africa. At each hospital, senior staff identified two doctors and two nurses who regularly provided care for women who had been raped. These doctors and nurses were interviewed using a questionnaire with both open-ended and closed questions. We interviewed 124 providers in 31 hospitals. A checklist that indicated what facilities were available for rape survivors was also completed for each hospital. Findings A total of 32.6% of health workers in hospitals did not consider rape to be a serious medical condition. The mean number of rape survivors seen in the previous six months at each hospital was 27.9 (range = 9.3-46.5). A total of 30.3% of providers had received training in caring for rape survivors. More than three-quarters of regional hospitals (76.9%) had a private exam room designated for use in caring for rape survivors. Multiple regression analysis of practitioner factors associated with better quality of clinical care found these to be a practitioner being older than 40 years (parameter estimate = 2.4; 95% confidence interval (CI) = 0.7-5), having cared for a higher number of rape survivors before (parameter estimate = 0.02; 95% CI = 0.001-0.03), working in a facility that had a clinical management protocol for caring for rape survivors (parameter estimate = 2; 95% CI = 0.12-3.94), having worked for less time in the facility (parameter estimate = -0.2; 95% CI = -0.3 to -0.04) and perceiving rape to be a serious medical problem (parameter estimate = 2.8; 95% CI = 1.9-3.8). Conclusion There are many weaknesses in services for rape survivors in South Africa. Our findings suggest that care can be improved by disseminating clinical management guidelines and ensuring that care is provided by motivated providers who are designated to care for survivors. [ABSTRACT FROM AUTHOR]