Domestic Violence and Pregnancy

Dec 02, 2013, 04:26 PM

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 your professional or personal life. Start with open questions such as “How are things at home? Are you supported? Is there anyone you are afraid of”, and also use direct questions “Are you shouted at or called names? Have you been pushed, threatened, hit or hurt?” Even if she chooses not to tell, a woman will appreciate being asked. Look, listen, and believe her. You can give information cards and numbers “in case you or a friend might need it in the future”. If a woman does test your reaction, or tells you about abuse, listen and believe her. Validate her experience – ‘what happened to you was wrong, and not your fault’. Document the events with her permission, in confidential notes, as this may be important later. Do not write about this in the handheld notes as that may endanger her and lead to retaliation. Offer support and follow up. Simple kindness, courtesy, reliability and trustworthiness go a long way to allaying women’s fears, particularly that her children will be removed which rarely happens. After all, her partner has told her she is worthless, unstable, provokes the violence, won’t be believed and is a bad mother. Advise her that she can get help, from specialist domestic violence services, housing, lawyers and psychological support which may be required to recover from years of abuse.

Pregnant women suffering domestic violence are more likely to seek help from health care personnel than any other statutory service. The key stages of a helpful and effective response (whether as an friend, individual, or institution) are: 1. Be aware of, and recognise abuse 2. Provide a safe, quiet environment 3. Identify and aid disclosure 4. Document the abuse with her permission 5. Make a safety assessment, give information and ongoing support. Good practice dictates that maternity services should have robust policies for ensuring women’s safety and confidentiality, providing information and referral pathways for those who disclose.

Commissioners of services must assess local need and provide effective multiagency services, preferably to women of all risk categories. All pregnant women are at high risk of complications affecting them and their offspring, and risk can change quickly. Providers must have regular, updated training for all staff in maternity services, not just midwives, but doctors, receptionists, and interpreters. There is no evidence that screening, or bureaucratic ‘top-down’ models work, but services need authentic champions in leadership positions. It is preferable for training to be provided by domestic violence agencies, to be tailored to the participants, and for face-to-face relationships to underpin embedded services, working alongside community partners. Of course, child protection is an issue, but women must be treated as ends in themselves, not just as a means to others’ ends. ‘in-reach’ models of service delivery into health services, with agreed policies about information sharing are more likely to be effective. Alongside regular data collection, a key indicator of the quality of domestic violence services is whether they are trusted enough to be accessed and used by staff.

In summary, it takes a community to look out for pregnant women and protect them from the emotional, psychological and physical impacts of intimate partner violence. As Dr Holmes, said…. “God forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly or selfishly”. With proper training, skilled support and non-judgemental attitudes, we can all act together to keep pregnant women, and their children, safe.

#Domesticviolence, #publichealth, #healthcare