In this study, we observed that only four of 23 registered acute care hospitals in Goma cared for a total of 7,048 victims of sexual violence admitted during a 22 months period. Resources to care for sexually abused females were consistently available at a single non-governmental organization-run hospital only. The other three health care facilities faced comprehensive shortages of resources. At one selected hospital, the majority of women presenting after sexual violence received acyclovir and/or antibiotics to treat or prevent sexually transmitted diseases, whereas post-exposure HIV prophylaxis or vesico-vaginal repair surgery was provided to only few victims.
Interestingly, the four health care facilities which were identified out of all acute care hospitals in Goma to provide regular care for sexually abused women were all run by non-governmental institutions. A historical reason for this may be the availability of resources, in particular medical personnel (e.g. gynaecologists), to provide care for sexually abused women at these institutions. Over the years, apart from other medical fields, these institutions evolved as specialized centers to provide care for victims of sexual violence in Goma. Finally, the local health care authorities selected the four institutions as referral centers for the care of sexually abused females.
Shortages of resources to care for victims of sexual violence in the few Goma hospitals appear multifaceted. On the one hand, there is an obvious lack of adequately trained health care providers, such as physicians able to perform gynaecological surgery, anaesthetists, and psychiatrists or psychologists, to care for sexually abused females in- and outside the hospital. Our results regarding inconsistencies in post-discharge care of sexually abused females are in line with the findings of the United Nations panel reporting unmet needs of victims of sexual violence, particularly in remote areas [7
]. The lack of material resources (e.g
. surgical and anaesthesiological equipment, drugs) poses a relevant barrier to adequate care of victims of sexual violence. The only exception is chinolone and tetracycline antibiotics as well as HIV tests which were reported to be consistently available in all hospitals.
Selected data from the DOCS Hospital suggest that the majority of females following sexual violence receive acyclovir or antibiotics to treat or prevent sexually transmitted diseases. In contrast, administration of post-exposure HIV prophylaxis was very low. Given the high prevalence of HIV infection among African soldiers [8
], prescription of post-exposure prophylaxis is recommended for sexually abused females within 48-72 hours of rape [9
]. Two reasons can explain the strikingly low rate of post-exposure HIV prophylaxis in the present study cohort: First, women frequently seek medical care following sexual violence only after a time delay that precludes effective post-exposure prophylaxis. Secondly, our results suggest that drugs for post-exposure HIV prophylaxis are in short supply and can therefore not even be administered to patients presenting within 48-72 hours following sexual violence.
The low number of hospitals caring for victims of sexual violence together with the lack of human and material resources has resulted in a substantial impediment to medical care provided to sexually abused females in the North Kivu province. Currently, it is estimated that approximately 1,000 women and girls are waiting for medical care following sexual violence in rural territories around Goma (e.g. the Rutshuru, Lubero, Masisi, and Walikale regions) since Nov 2009 (data retrieved from the Health District Office Goma, Jan 2011). Considering that many victims of sexual violence never seek medical care and that some who seek medical care do so at smaller hospitals or clinics outside of Goma, our survey has the potential to relevantly underestimate the burden of sexually abused females in Goma. The fact that some females do not present to medical institutions at all while others present only with a relevant delay may diminish the benefit of sufficient human and material resource availability to provide medical care for sexually abused women. Aside from functioning referral systems and transportation facilities, educational campaigns are needed to inform victims about the time sensitivity of post-rape care.
Our study carries several limitations. First, the study was not piloted, and resources considered necessary to care for sexually abused females in this study have not been validated or shown to improve the care and outcome of victims of sexual violence. In accordance with international recommendations and practical experience of the authors, these materials were regarded as indispensable to provide adequate patient care. Second, considering the small sample size of surveyed hopitals, our results must not be extrapolated to other areas of the North Kivu province or Democratic Republic of the Congo. Since the hospitals in Goma are referral hospitals for the North Kivu province, it is, however, likely that medical facilities and resources to provide care for victims of sexual violence are even more limited in remote areas of the region. Third, our study evaluated only three indicator medical therapies provided to victims of sexual violence at a selected hospital and did not comprehensively evaluate the medical care provided to sexually abused females in Goma. This weakens the conclusion of our study that resource restraints substantially affect the quality of patient care. Finally, it is noteworthy that not all information collected during interviews could be verified during on-site visits of the study hospitals.