Domestic Violence and Pregnancy
In some parts of the world, domestic violence against pregnant women is more prevalent than diabetes or hypertension, but receives far less attention. In this podcast, Dr Susan Bewley of Kings College sets out the facts about domestic violence involving pregnant women and suggest what healthcare professionals can do to help.
Transcript “The woman about to become a mother, or with her newborn infant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden or stretches her aching limbs….” So said Dr Oliver Wendall Holmes in 1843, beautifully describing how all of us should treat women having children – whether that be husbands, partners, family members or professionals. He reminds us that women and children are precious and mothering is important.
Domestic violence and abuse towards pregnant women or new mothers is hidden, a taboo and yet highly prevalent. Pregnancy is a recognised risk factor for murder, and domestic violence is a feature in at least 1 in 7 maternal deaths from obstetric causes. What is going on? Whilst most intimate relationships are respectful, others are coloured by issues of power, coercive control and violence including rape and sexual assault. Abuse in pregnancy is common and is found throughout the world. Rates of abuse during pregnancy and after have been found ranging from 1 in 30 to 1 in 3 women. This is more common and yet less focused upon than diabetes or hypertension.
But let’s start with unwanted pregnancy: A recent meta-analysis has shown that a quarter of women seeking termination globally have experienced domestic violence within the previous year. Rape related pregnancy has a particularly high chance of leading to termination. There are high rates of physical, sexual and emotional violence amongst women seeking abortion, and healthcare professionals should particularly be aware of the clinical factors associated with greatest risk: previous and repeat termination, lack of contraception, initially planned pregnancy, ultrasound re-dating and the partner not being told about the termination. There are also potential associations with young age, marital status, ethnicity and low household income. Domestic violence compromises both the safety and health of the woman requesting the termination, and potentially that of her partner and any existing children. In attempting to prevent repeat termination, a narrow service focus, say on long acting contraception, that excludes addressing the wider safety needs of a woman in a violent relationship, might leave her less likely to become pregnant but just as vulnerable to abuse. So, good practice dictates that termination services should have robust policies for ensuring women’s safety and confidentiality, providing information and referral pathways for those who disclose.
Moving to ongoing pregnancy. Violence and abuse can start and escalate during pregnancy, and they are especially severe post partum. There are a host of ‘red flag’ associations ranging from late booking, frequent non-attendance, multiple non-specific admissions and discharge against advice, to clinical conditions such as antenatal depression, alcohol and substance misuse, abdominal pain, vaginal bleeding, injuries and falls, diminished fetal movements, miscarriage, growth restriction, prematurity and stillbirth and, after the birth, infections or torn stitches from forced sex. Some women are abandoned, others might have overbearing or oversolicitous partners who talk for or undermine them. In short, you don’t know what is going on in private unless you ask in privacy – all women must be given confidential time. And, thanks to the stigma, shame, isolation, fear and belittlement women suffer, they won’t tell you about abuse unless they feel safe that your response will be non-judgemental and understanding. You can help by learning about domestic abuse, and making it a routine question to ask women whether in yo...