Maternity staff are well-placed to help end violence to women and unborn children

Summary

Solace is a London-based charity working to end violence against women and girls. In this blog, Chief Executive, Fiona Dwyer highlights the increased risk of abuse during pregnancy and how healthcare staff can help identify and reduce significant harm.  

Content

As a professional who has worked on ending violence against women and girls (VAWG) in the United Kingdom for almost 13 years, I wanted to reflect on how domestic abuse is still not prioritised within maternity services as it should be.

Pregnancy: A time of increased risk

Pregnancy is often a time when domestic violence either starts or escalates – the oft cited statistic is that domestic abuse starts or escalates in 30% of cases. It has been referred to as ‘double-intentioned violence,’ as physical attacks directly affect both the mother and the unborn child.[1]

The Confidential Maternal and Child Health Enquiry in England and Wales indicated that 39% of the 70 women who had died and were considered in the Enquiry experienced domestic abuse during pregnancy, and that 19 died as a direct result of the abuse.[2]

The Enquiry also found that of the 70 women who had died of direct or indirect causes:

• 81% found it difficult to access antenatal services
• 77 % were in contact with their local social services
• 64% of mothers and children were in contact with child protection services
• 62% of pregnant women under the age of 18 had experienced domestic violence in the home.[3]

Further studies have also found that where abuse is present, there is an increased risk of:

• Miscarriage (women who were subjected to domestic violence in pregnancy are between 2.5 and 4 times more likely to miscarry).[4]
• Placental abruption[5]
• Premature birth[6]
• Low-birth rate
• Disrupted mother-child attachment
• Increased physical or sexual violence[7]
• Direct pregnancy related physical abuse, where abused women have said that they are more likely to be kicked in the abdomen or breasts during pregnancy[8]
• ‘Neuro-developmental’ trauma in the child.[9]

Women may also be prohibited from attending antenatal appointments and many are ambivalent about their pregnancy, particularly if it is as a result of sexual or reproductive coercion, which has implications for their own self-care and again for attachment with their child.[10]

Indirect effects include other risk factors which may have implications for both mother and child such as sexually transmitted infections; urinary tract infections; HIV; substance and alcohol misuse; depression; smoking and low-weight gain.[11]

Barriers to ‘routine enquiry’

Routine Enquiry for domestic abuse in pregnancy (asking all women at assessment about abuse regardless of whether there are any indicators or suspicions) was introduced over 20 years ago but sadly, abuse is still not being proactively identified by health professionals, despite NICE Guidelines[12] being introduced.

A number of reasons (beyond training) have been suggested, including:

• fear of offending the woman
• nervousness about dealing with a disclosure
• staff feeling it is not within their remit.[13]

Despite these findings, our experience at Solace is that women actually welcome being asked and do not feel offended.

Poorly translated guidance: a case study

Beyond my professional life working in the VAWG sector, over the past 13 years that I have lived in the UK, I sadly do not have one friend or colleague who has recounted a positive experience with routine enquiry.

One friend’s experience has always stayed with me.

Jemma (not her real name) was asked about her experiences of domestic abuse in front of her husband – “no domestic abuse?”

It was particularly galling given that Jemma could see a well-worded question on the form being completed. The midwife then made a joke about Jemma being a perpetrator – “oh I can see you’re not beating him either”, and proceeded to ask about additional complications.

“No mental health problems? No drug problems? You have a nice house?”

During her following two appointments, the same safeguarding boxes were automatically ticked for ‘no’ in Jemma’s notes, with no further discussion.

Many other women have detailed similar experiences of box-ticking without being asked, or being asked very poorly.

These forms have been worded carefully to help aid conversations sensitively and effectively, to ultimately prevent harm to the parent and child. Seeing them translated so poorly is a missed opportunity to identify risk and put the appropriate safeguards and support in place for both the woman and the child.

Creating the right culture is key

Experiences like Jemma’s made me more passionate about driving culture change amongst health professionals.

Training is an excellent first step, but in itself does not lead to the culture change required within health services to support all pregnant women. There are still too many myths amongst professionals about domestic abuse and the links to poverty, meaning that assumptions are often made about pregnant women’s home life situation.

Where routine enquiry is embedded within the culture of the service, it works far more effectively. This cultural shift includes developing a proactive and supportive response for women from clinicians. Adding in additional supervision for midwives and other health professionals, including dip-sampling and action learning can also make a real difference.

Joint working with specialist domestic abuse agencies, including co-location can also be very helpful in improving patient safety outcomes. Health professionals are generally not afraid of asking health questions; the risk of domestic abuse in pregnancy should be no different.

How can Solace help?

Solace has had co-located services within health for over a decade and continues to provide training and expert support to professionals across primary, acute and mental health services. We have seen a real difference where health services have partnered with Solace – with mutual benefits for both agencies and also an enhanced response to women and children living with domestic abuse. I would recommend this in every local area.

Safelives (2016 and 2021)[14] as well as The National Pathfinder programme[15] in Health echoed our findings that working in partnership with specialist organisations, particularly where co-locations are possible, has a huge impact on the health response to domestic abuse.

Solace provides a range of holistic support services to survivors in London, right from crisis through to recovery. For any professional who identifies concerns, we are here to support – you can contact us via our website www.solacewomensaid.org, where we have a range of resources. For London services, our advice line is  0808 802 5565.

For health professionals who want to learn more, the National Centre for Clinical Excellence has developed a robust interactive flowchart to support health professionals to ask about domestic abuse in a supportive way.

NICE Pathway: Domestic violence and abuse overview

Similarly, the Royal College of Nursing has collated good practice examples on their website.

Royal College of Nursing: Domestic abuse national guidance

Fiona Dwyer

References

[1] Kelly, L (1994) 'The Interconnectedness of Domestic Violence and Child Abuse: Challenges for Research, Policy and Practice', in Mullender, A and Morley, R (eds.) Children Living With Domestic Violence, London: Whiting and Birch.

[2] Lewis, G (ed.) (2007) The Confidential Enquiry into Maternal and Child Health (CEMACH): Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer - 2003-2005. Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom, London: CEMACH.

[3] Ibid

[4] Schornstein, S (1997) Domestic Violence and Health Care: What every professional needs to know , Thousand Oaks, California, USA: Sage; Nur, N. (2014) ‘Association between domestic violence and miscarriage: a population-based cross-sectional study among women of childbearing ages, Sivas, Turkey’, Women Health, 54(5), pp.425-38.

[5] Leone, J.M., Lane, S.D., Koumans, E.H., DeMott, K., Wojtowycz, M.A., Jensen, J. and Aubry, R.H. (2010) ‘Effects of intimate partner violence on pregnancy trauma and placental abruption’, Journal of Women’s Health, 19(8), pp.1501-1509.

[6] Siddique, H. (2016) ‘Domestic violence 'doubles risk of premature birth'’, The Guardian, 9 March. Available at: https://www.theguardian.com/society/2016/mar/09/domestic-violence-pregnant-women-doubles-risk-premature-birth-survey (accessed 12.05.21).

[7] See for example Taft, A, Watson, L, and Lee, C (2004) ‘Violence Against Young Australian Women and Association with Reproductive Events: A Cross-Sectional Analysis of a National Population Sample', Aust N Z J Public Health, Vol. 28 and McWilliams and McKiernan (1993)

[8] BMA (2007) Domestic Abuse – A Report from the BMA Board of Science, London: British Medical Association

[9]See for example the work of Bruce Perry, https://www.childtrauma.org/brain-dev-neuroscience  (last accessed 10.05.21)

[10] Callaghan, J., Morrison, F. and Abdullatif, A. (2018) Supporting women and babies after domestic abuse: A toolkit for domestic abuse specialists,  London: Women’s Aid Federation of England.

[11] Cunningham, A and Baker, L. (2004) What about me! Seeking to Understand the child’s view of violence in the family, Centre for Children and Families in the Justice System, London, Ontario, p. 56.; Cook, J. and Bewley, S. (2008) ‘Acknowledging a persistent truth: domestic violence in pregnancy’, J R Soc Med., 101, pp. 358-363.; Alhusen, J.L., Ray, E., Sharps, P. and Bullock, L. (2015) ‘Intimate Partner Violence During Pregnancy: Maternal and Neonatal Outcomes’, Journal of Women’s Health, 24(1), pp. 100-106.

[12] NICE (2016) ‘Domestic violence and abuse’, London: National Centre for Clinical Excellence.

[13] Baird, K.M., Saito, A.S., Eustace, J. and Creedy, D.K. (2018) ‘Effectiveness of training to promote routine enquiry for domestic violence by midwives and nurses: A pre-post evaluation study’, Women and Birth, 31(4), pp.285-291.

[14] Safelives (2016) A Cry for Health: Why we must invest in domestic abuse services in hospitals, London: Safelives; Safelives (2021) ‘We only do bones here’Why London needs a whole-health approach to domestic abuse, London: Safelives. Both reports are available here: https://safelives.org.uk/policy-evidence (accessed 12.05.21)

[15] The Pathfinder project was a 3-year project across 8 sites in England aimed at transforming the health response to domestic abuse. The project was led by Standing Together alongside AVA, Imkaan, IRISi and Safelives. The toolkit was launched in 2020 and is available at: https://www.standingtogether.org.uk/blog-3/pathfinder-toolkit (accessed 12.05.21)