The Role of a Midwife in Domestic Violence Cases

ANSWER
The midwife’s role in domestic violence and public health.
Why is domestic violence an issue of public health concern for midwives?
According to the most recent triennial maternal mortality report (CEMACH, 2004), eleven new mothers were murdered by their partners within six weeks of giving birth between 2000 and 2002. According to the report, domestic violence is a risk factor for maternal death from any cause. According to this report, 14% of all women who died reported being victims of domestic violence. Over three years, this equates to 51 women in England, Wales, and Northern Ireland. All risk factors must be carefully considered to make progress in reducing maternal mortality. Risk assessment is used to determine the type of care a woman will receive during pregnancy and labor. For antenatal and intrapartum care, this midwifery role is already well established.

Epidemiology
Domestic violence is widespread. For a single day, September 28, 2000, crime statistics were obtained and made public by British police forces. On that day, the police received 1300 calls reporting domestic violence. Domestic violence occurs every six to twenty seconds, based on this data. The majority of the victims are women. According to Home Office statistics, two women die in Britain each week due to violence perpetrated by their current or previous partner (Mirrlees-Black, 1999). A study in London discovered that 23% of women in antenatal and postnatal wards had experienced domestic violence in their lifetime. Three percent of these women had experienced domestic violence during their current pregnancy (Bacchus, 2004).

The consequences of domestic violence
The definition of domestic violence varies greatly. Physical violence is not required. This is a problem. Blurring lines between the severity of abuse hampers the collection of statistics. While some may argue that no abuse is acceptable, a distinction must be made. Domestic violence may be triggered by pregnancy; it may begin at this time or change in nature, sometimes becoming mental rather than physical but sometimes focusing on blows to the abdomen. The puerperium is a particularly vulnerable period (CEMACH, 2004).
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Domestic violence has a significant economic impact on society. The costs of dealing with 100,000 women seeking medical help each year due to domestic violence and the fact that 17 percent of homeless applications for shelter are caused by domestic violence may cost London alone approximately £250 million each year. Support systems are overburdened; every day, 7 000 women and children seek safe havens (Seymour, 2001).

Miscarriage, premature labor, low birth weight, and intrauterine fetal death increase when a pregnant woman is physically abused. Domestic violence may increase a pregnant woman’s likelihood of smoking, drinking alcohol, or using drugs, which can harm the pregnancy and fetus. Domestic violence is linked to depression and suicidal ideation. Trauma to the abdomen increases the risk of life-threatening placental abruption, uterine rupture, other internal organ rupture, and fetal risks. Women who have experienced domestic violence are less likely to be able to obtain antenatal care; many books are late, and a significant proportion does not book at all. They have difficulty accessing care and frequently miss appointments, change addresses, and have no reliable way of being contacted. Frequently, the partner will exert suffocating control over them by accompanying them to the midwife, answering questions, and remaining present during examinations (Mezey, 2002).

Initiatives to combat the issue
The National Service Framework (2004) for Children, Young People, and Maternity Services of the Department of Health emphasizes the importance of identifying victims of domestic violence and includes pointers for recognition and action during pregnancy and recommends that staff be aware of these aspects. Some emphasis is placed on the environment’s supportiveness and the sensitivity of the abuse investigation.

Domestic violence has received special attention from the government (The Government’s Proposals on Domestic Violence, 2003). Parliament passed the Domestic Violence, Crime, and Victims Act of 2004. The Police and Criminal Evidence Act of 1984 has expanded police arrest powers for common assault. This has impacted dawn raids to apprehend offenders (Bird, 2004). According to Dimond (2005), to truly address the issue of domestic violence, people in general, including healthcare providers, must become involved. It is already the case that if an assault causes a miscarriage, the offender can be charged under Section 58 of the Offences Against the Person Act 1861. (Bristol Evening Post, 2004). When an assault causes premature birth, and the child dies, the charge is manslaughter. On behalf of the government, the Home Office is taking the lead on this issue. Domestic violence courts are being planned. A Domestic Violence Cluster Court is being tested in Leeds. The goal is to shorten the process of dealing with perpetrators while increasing the length of custodial sentences. The Department of Health advocated routinely questioning pregnant women about domestic violence in 2000. The Royal College requested this of Obstetricians and Gynaecologists, the Royal College of Midwives, and NICE. The Royal College of Midwives recommended in a position paper in 1999 that abuse be recognized and documented and that such women be given information to make their own decisions.
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It is acknowledged that a woman must be able to find the assistance she requires when she is ready (Smith, 2005). While the woman can be assured of confidentiality, the scope and limitations of that confidentiality must be made clear. For example, confidentiality must be broken if she already has children and there is a risk that they will be subjected to domestic violence. If there is a danger to the fetus after birth, the woman and midwife’s confidentiality must be broken. The fetus does not have any legal rights until the moment of birth.

There have been significant projects in Wales and Bristol to screen pregnant women for domestic violence and follow up on positive responses. Initiatives have also been launched in Leeds and London. A study conducted in Bristol and funded by the Department of Health found that more women disclosed it when midwives were trained to ask about domestic violence. Midwives desired additional training; without it, only 10% of midwives would choose to inquire about domestic violence. Midwifery training in questioning has increased midwives’ confidence in this area (Baird, 2005). The Bristol study was critical in determining the impact of routine questions about domestic violence on midwifery education. The involvement of multiple agencies in the work and education was evident. Talking to the woman alone, precisely without the presence of her partner, was a critical aspect of the work on disclosure (Merchant, 2001). The question is unlikely to be beneficial if the woman is not asked alone or if there is no effective follow-up (Ward & Spence, 2001). The only time the abusive partner will let the woman be alone is when she goes to the bathroom. As a result, posters with contact information for women’s refugees, social services, victim support, and so on must be available in this location. Information can also be pre-printed on maternity records so that if a partner sees it, it is evident that it is not explicitly aimed at that woman. She is less likely to suffer further abuse due to him seeing it. Another idea is to have a poster in the women’s restroom indicating that if the woman is being abused, she should mark her routine urine container in some way that alerts the midwife but no one else that she is in danger from domestic violence. Women from ethnic minorities who do not speak English face additional challenges. It is critical to employ an interpreter who is not a family member.

The Bristol study was a pilot to inform midwives about their education needs when asked about domestic violence. It was not intended to be a study to collect evidence about whether it is adequate to encourage disclosure and whether subsequent information and support are beneficial in reducing the problem.

QUESTION
The Role of a Midwife in Domestic Violence Cases