The Midwives Role in Domestic Violence Essay

Domestic violence has been with us throughout the ages. A brief overview of the subject shows that it has taken many forms and significantly, we note that the phenomenon is defined in many different ways. To an extent, these ways are determined by the society, the environment and to an extent the chronological time of the events. Acts and behaviour patterns which can be considered acceptable in one social construct can be completely unacceptable in another. We can cite an example enshrined in British law, that up to 1824 a husband was legally entitled to beat his wife to any degree as long as he did not use a stick that was larger in diameter than his thumb, hence giving rise to the expression “rule of thumb” (Boyle A et al. 2004). The Midwives Role in Domestic Violence Essay

Studies have shown (DOH 2000) that women who are abused experience an average of 35 episodes of domestic violence before they make the decision to seek help. The same study details the many and varied ways that women will ask for help. Some are clearly unequivocal and overt by reporting to the police, the social worker or some other statutory representative or healthcare professional, while others may not present overtly and the signs of abuse may be noticed by another person who then intervenes and may thereby represent a channel of communication that may be what the victim has been waiting for. A third group appear to enter a phase of complete denial. They may present to a healthcare professional with signs and symptoms that are highly suspicious of domestic violence, but when challenged, may deny the possibility and produce a string of plausible explanations as to just how certain injuries had been sustained. (Yura H et al. 1998). As with any situation that affects the human condition there are inevitably a spectrum of other presentations behind these extremes and although we have chosen to present three particular stereotypes, we note that each individual case is unique, has its own unique trigger factors and response patterns, but is almost universally distressing and degrading to the victim of such violence. In the circumstances that we are considering here the case is rather different from the majority insofar as we are specifically considering the role of the midwife in dealing with domestic violence. It follows from this that violence towards the mother not only affects her but potentially can cause both direct and indirect morbidity with the unborn or newborn child. There is also the effect that it can have on any other children in the family, but we shall discuss these issues in greater detail in the review itself. The Midwives Role in Domestic Violence Essay

The whole topic of domestic violence has been given a degree of prominence in recent years with bodies such as the American College of Emergency Physicians (ACEP 1996)  and their British counterpart, the BAEM, (BAEM 1993)
issuing protocols and guidelines relating to suspected domestic violence and the British Government launching a number of initiatives which are specifically directed at targeting the whole area of domestic violence and also at helping to support the victims of such violence.

Methodology

The method which was adopted for this particular review was to take the initial step of both considering and reflecting on the title, and the implications of the title, for a short period of time and to read through some relevant general literature surrounding the subject in order to get an overview of the whole area. (Dempsey P A et al. 2000).  Shortly after this, further reading was done to encompass the areas of the research patterns that had emerged historically in this area. (Vickers, A. J et al. 2001). This was done over a period of about two weeks and covered about 40 different texts. During this period appropriate references were noted and cited papers were located, read and recorded. Some computer sources including CINAHL, MIDIRS and OVID, together with the Cochrane Data base, were accessed for further background (and in some cases specific)  information. The computer sources were not directly utilised in the preparation of the review itself, as the main basis of the literature used was accessed in hard copy from both the local Post- Graduate centre and also the local University library (client: you might like to personalise this) where the databases for appropriate literature on the subjects could be searched and retrieved together with peer-reviewed journals. (Macnee C L 2004). It should be noted that the majority of papers retrieved and consulted were from UK based peer reviewed journals and UK based authors, but a number were from international sources. As a general rule, the primary searches were done using material that was not more than 10 years old, although some older papers were consulted when it was necessary to put particular points into a historical perspective.  (Rees C 2003). The Midwives Role in Domestic Violence Essay

Approximately 45 papers were both read and assimilated in the preparatory stages of this review, both in the area of domestic violence and in the area of specific midwife involvement in the investigative process. Further papers were read in the area of critical analysis of peer reviewed literature. In total, over 120 papers were consulted in the preparation of this review. The evidence was assembled and assessed in a critical and dispassionate form and them the most relevant portions were presented in a logical fashion in the final review. ( Berwick D  2005)

Having been able to assess and present the available evidence, it then became possible to take a view on the evidence base thus collected, a summary made and conclusions reached. The conclusions and summary were then used to establish where there were gaps in the literature. (Hek G et al. 2000).  This allowed for a number of further conclusions relating to the direction of necessary research in the area. The Midwives Role in Domestic Violence Essay

Review

If we consider the literature on the subject of domestic violence it quickly becomes apparent that the spectrum of domestic violence, at least in terms of definition, is huge. Different papers appear to define and describe the phenomenon in quite different and disparate ways. Boyle (A et al. 2004) details “abuse, intimate partner abuse, interpersonal violence, wife battering, or violence against women” as being some of the terminology that is in common usage for the phenomenon and also highlights the consideration that other terms such as  “wife beating and violence against women”  are also commonly accepted synonyms for the phenomenon but should be regarded as very unsatisfactory for the process in general terms, as it directly implies that the violence is a one way phenomenon from a man directed against a woman. While it is true that this type of assault constitutes the overwhelming majority of cases, one must not overlook the possibility of domestic violence directed against men from their female partners and also against both men and women in homosexual relationships. (Mcleod M 1984). The Midwives Role in Domestic Violence Essay

Another confounding factor which becomes apparent when making any degree of critical appraisal of the literature, is the fact that there appears to be a considerable disparity in the definition of how one can define the perpetrator in domestic violence situations. How, for example, does one categorise the male victim of domestic violence if he is being attacked in retaliation for previous assaults on his wife?  Boyle cites two opposing definitions as an example to illustrate the point. The Coker study (Coker A l et al. 2000) only categorised an incident as “domestic violence” if the perpetrator had been having intimate relations with the victim for more than three months whereas, by contrast the Tham study (Tham S W et al. 1995), defines the perpetrator as “someone who might have been expected to be supportive”. The two definitions being clearly miles apart in terms of reflection of the relationship between the offending parties and thereby making meaningful comparison between papers very difficult.  In the same way we can point to any number of papers which define domestic violence as physical assault where as a significant proportion of what may be more appropriately called domestic abuse may have a psychological, financial or even a purely verbal element in it, but it can still contribute to a significant amount of psychological trauma in the victim of such an arrangement. As we have commented in the introduction there is also the element  of “collateral damage” to other members of the family who may witness domestic violence  even though it may not be directed overtly at them. We shall discuss the “psychological erosion” effect that such witnessing may have on children in the family and how it may appear to “legitimise” this behaviour in their eyes and how it may subsequently manifest itself in a belief that in later life violence is an appropriate ploy to settle intra-family disputes. The Midwives Role in Domestic Violence Essay

If we consider a comparatively recent study by Mirrlees-Black (C 1999), we can point to a substantial evidence base that suggests that domestic violence in the sense of physical violence is more often than not perpetrated by a comparative stranger, the more subtle forms of psychological and financial abuse are more likely to be perpetrated by a “significant other” with a closer and more intimate relationship than overt violence.

If we accept all of these caveats and consider the aetiology of domestic violence in general terms, a number of different authorities point to a number of different factors which appear to be significant in the genesis and perpetuation of the abusive and violent situation. Boyle suggests that controlling behaviour in the perpetrator is significant and Dearwater (S R et al. 1998) suggests a crescendo scenario starting from verbal abuse stemming from a failure of respect on the part of the perpetrator, which can then escalate into one of the other forms of controlling behaviour patterns. Controlling behaviour can be considered as economic control as well as physical control.The Midwives Role in Domestic Violence Essay

For a definitive and considered general statement on the issue we can look to the World Health Organisation who has defined violence as:

…the intentional use of physical force or power, threatened or actual…that either results in, or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation (WHO 1996)

If we consult the literature for an appreciation of the incidence of domestic violence, we immediately face the problem (quite apart from that of actual definition cited above) of knowing the extent of domestic violence that is unreported. Clearly we can cite figures that reflect the number of cases that are reported to the police or are suspected at the A&E departments across the country, as these are figures that are routinely collected and are in the public domain. Abbott (J et al. 1995), in trying to understand the degree of the problem, undertook a large cross sectional study and commented on the reluctance of many victims to disclose significant information. Their study (albeit American based) suggested that 11.7% of women who attended the A&E Depts. included in their study,  were attending because of either injuries or stress directly referable to domestic violence in one of its many forms. Of all the women seen in the A&E Depts., 2% were there as a direct result of physical trauma sustained  directly from an abusive relationship, and this particular study suggests a staggering 54.2% lifetime prevalence rate for domestic violence in the populations of women who were seen in the A&E Depts. during the period of the study. This may well reflect the comments made in the opening paragraph of this review that the degree of domestic violence is as much a factor of the culture of the perpetrator and definition of the act as much as any other factors. This is illustrated  by consideration of a comparison with a similarly constructed UK study (Boyle A A et al. 2003) which found that 1% of women attending the A&E Depts in the study were there as a direct result of direct physical violence and the same authors calculated the overall lifetime prevalence rate for domestic violence in this population to be in the region of 22%.   This second set of figures is more nearly in keeping with the majority of other studies in the area (viz. Dearwater S R et al. 1998).The Midwives Role in Domestic Violence Essay

A smaller Scottish study (Wright J et al. 1997) considered an A&E dept seeing 60,000 cases per year and found 19 cases of overt (incontrovertible) domestic violence in a two month period. Another factor which may be considered to be implicit in the term “domestic violence” is the fact that the violence is considered to have occurred in the home. This is not universally the case. A rather older study (Fothergill N et al. 1990) found that between 15% and 20% of cases of assault occurred at sites away from the victim’s home. One of the overriding factors that must be considered in any type of critical analysis of the figures is that part of the apparent disparity in both incidence and prevalence is due to the structure of the studies. There appears to be a distinct overrepresentation of victims of domestic violence in the populations that present to A&E Depts. If we compare these figures with those obtained from more community based studies such as the British Crime Survey (cited in Mirrlees-Black C 1999) we find that lifetime prevalence figures are in the region of 26% for women and 17% for men and annual prevalence figures in the same study are quoted as 5.9% and 4.9% respectively.

We have made mention of some of the demographic elements earlier. If we consider these in rather more detail, we can point to studies (Roberts G L et al. 1996) which suggest that, (again in a population of A&E Dept attenders), over 15% of men had experienced at least one episode of domestic violence in their lives and this was approximately half that of a similar group of women. Factors that were found to be independent risk factors for the risk of domestic violence include lack of education, alcohol misuse, unemployment, low income, and recreational drug use (Kyriacou D N et al. 1999). The Midwives Role in Domestic Violence Essay

In specific consideration of our investigation in the role of the midwife in the issue of domestic violence, we note that there was a widely reported study which suggested that being pregnant was also an independent risk factor for abuse (Gelles R J 1988). This was considered to be a landmark study in the area at the time of its publication, but we note that other reputable and carefully constructed studies have failed to replicate the original author’s findings. (McGrath M E et al. 1998. Other relevant factors include comparative youth as a risk factor and there are also studies that suggest that post-partum status carries a higher risk of domestic violence than does antenatal status. (Gazmararian J A et al. 1996). The same study also provides evidence to support the view that both the severity and the frequency of attacks of overt physical violence appears to escalate as pregnancy progresses and passes to the post natal period reaching a peak at between 6-9 months post partum.

In terms of identification of the potential victim of domestic violence the midwife (or other healthcare professional) should be alert for a number of signs and symptoms that have a high index of suspicion for domestic violence. (Staquet M J et al. 1998).  Different studies have identified different characteristics of the abused partner but there are a number of common factors which appear to be reasonably consistent throughout the major studies of the subject.The Midwives Role in Domestic Violence Essay

The most common consensus is that the victim will tend to demonstrate an increased usage of healthcare facilities. In general terms Bergman (B et al. 1991) is typical in this regard and documents an increased utilisation of all forms of medical care, most notably hospital admission which were found to be four times higher in this group than the admission rate in the general population.  even though we must accept that in the figure derived for the “general population” there will inevitably be an unknown, but probably significant, number of undetected cases of victims of domestic violence. Intuitive examination of the issue might suggest that there would be an increase in the usage of the psychiatric services and indeed, the same study points to a higher utilisation of facilities that are associated with alcoholism, depression and also deliberate self harm in the victims of domestic violence group. In terms of the index of suspicion for the visiting midwife, the authors suggest that women who present with multisystem, frequent and poorly defined complaints should be regarded as being the most likely to have an underlying problem with domestic violence, even they may not wish to overtly communicate this fact top the healthcare professional, it should be regarded as a significant warning sign.

Other studies point to other warning signs. We have already commented upon the likelihood of repeated attendance being associated with domestic violence, but interestingly, one study. (Spedding R L et al. 1999) suggested that the time of presentation was also significant. For reasons that the authors did not enlarge or speculate on they found that assaulted women were more likely to present between 6 pm and 6 am when compared to those with unintentional injuries.The Midwives Role in Domestic Violence Essay

There is considerable discussion and debate in the literature related to whether these traits and characteristics suggest a causal or resultant relationship between observed symptomatology and the situation of domestic violence. On an intuitive level one can postulate that being the victim of domestic violence or being in a long-term abusive relationship may be sufficient cause to present to a healthcare professional with depression, and could easily lead to episodes of deliberate self harm equally Wadman (M C et al. 1999) considers the possibility that the personality traits that can be frequently associated with both a depressive personality and also the tendency to deliberate self harm, may also “confer an increased risk of entering an abusive relationship”. Examination of the current literature on this element does not help us to reach any clearer view on the issue other than to allow us to present the fact that there is clearly a dichotomy of opinion on the subject.

In specific regard to issues surrounding pregnancy we can also note that there is evidence to suggest that violence can be specifically related to such issues. (CMO 2000). Of all the women who died in a three year period (‘97-’99) with a death related to pregnancy, 12% had reported domestic violence at some stage prior to their death. The study did not make any direct observation (because it couldn’t) of a direct link between domestic violence and the death. The Midwives Role in Domestic Violence Essay

Methodology

The method which was adopted for this particular review was to take the initial step of both considering and reflecting on the title, and the implications of the title, for a short period of time and to read through some relevant general literature surrounding the subject in order to get an overview of the whole area. (Dempsey P A et al. 2000).  Shortly after this, further reading was done to encompass the areas of the research patterns that had emerged historically in this area. (Vickers, A. J et al. 2001). This was done over a period of about two weeks and covered about 40 different texts. During this period appropriate references were noted and cited papers were located, read and recorded. Some computer sources including CINAHL, MIDIRS and OVID, together with the Cochrane Data base, were accessed for further background (and in some cases specific)  information. The computer sources were not directly utilised in the preparation of the review itself, as the main basis of the literature used was accessed in hard copy from both the local Post- Graduate centre and also the local University library (client: you might like to personalise this) where the databases for appropriate literature on the subjects could be searched and retrieved together with peer-reviewed journals. (Macnee C L 2004). It should be noted that the majority of papers retrieved and consulted were from UK based peer reviewed journals and UK based authors, but a number were from international sources. As a general rule, the primary searches were done using material that was not more than 10 years old, although some older papers were consulted when it was necessary to put particular points into a historical perspective.  (Rees C 2003). The Midwives Role in Domestic Violence Essay

Approximately 45 papers were both read and assimilated in the preparatory stages of this review, both in the area of domestic violence and in the area of specific midwife involvement in the investigative process. Further papers were read in the area of critical analysis of peer reviewed literature. In total, over 120 papers were consulted in the preparation of this review. The evidence was assembled and assessed in a critical and dispassionate form and them the most relevant portions were presented in a logical fashion in the final review. ( Berwick D  2005)

Having been able to assess and present the available evidence, it then became possible to take a view on the evidence base thus collected, a summary made and conclusions reached. The conclusions and summary were then used to establish where there were gaps in the literature. (Hek G et al. 2000).  This allowed for a number of further conclusions relating to the direction of necessary research in the area. The Midwives Role in Domestic Violence Essay

Review

If we consider the literature on the subject of domestic violence it quickly becomes apparent that the spectrum of domestic violence, at least in terms of definition, is huge. Different papers appear to define and describe the phenomenon in quite different and disparate ways. Boyle (A et al. 2004) details “abuse, intimate partner abuse, interpersonal violence, wife battering, or violence against women” as being some of the terminology that is in common usage for the phenomenon and also highlights the consideration that other terms such as  “wife beating and violence against women”  are also commonly accepted synonyms for the phenomenon but should be regarded as very unsatisfactory for the process in general terms, as it directly implies that the violence is a one way phenomenon from a man directed against a woman. While it is true that this type of assault constitutes the overwhelming majority of cases, one must not overlook the possibility of domestic violence directed against men from their female partners and also against both men and women in homosexual relationships. (Mcleod M 1984).The Midwives Role in Domestic Violence Essay

Another confounding factor which becomes apparent when making any degree of critical appraisal of the literature, is the fact that there appears to be a considerable disparity in the definition of how one can define the perpetrator in domestic violence situations. How, for example, does one categorise the male victim of domestic violence if he is being attacked in retaliation for previous assaults on his wife?  Boyle cites two opposing definitions as an example to illustrate the point. The Coker study (Coker A l et al. 2000) only categorised an incident as “domestic violence” if the perpetrator had been having intimate relations with the victim for more than three months whereas, by contrast the Tham study (Tham S W et al. 1995), defines the perpetrator as “someone who might have been expected to be supportive”. The two definitions being clearly miles apart in terms of reflection of the relationship between the offending parties and thereby making meaningful comparison between papers very difficult.  In the same way we can point to any number of papers which define domestic violence as physical assault where as a significant proportion of what may be more appropriately called domestic abuse may have a psychological, financial or even a purely verbal element in it, but it can still contribute to a significant amount of psychological trauma in the victim of such an arrangement. As we have commented in the introduction there is also the element  of “collateral damage” to other members of the family who may witness domestic violence  even though it may not be directed overtly at them. We shall discuss the “psychological erosion” effect that such witnessing may have on children in the family and how it may appear to “legitimise” this behaviour in their eyes and how it may subsequently manifest itself in a belief that in later life violence is an appropriate ploy to settle intra-family disputes.

If we consider a comparatively recent study by Mirrlees-Black (C 1999), we can point to a substantial evidence base that suggests that domestic violence in the sense of physical violence is more often than not perpetrated by a comparative stranger, the more subtle forms of psychological and financial abuse are more likely to be perpetrated by a “significant other” with a closer and more intimate relationship than overt violence.The Midwives Role in Domestic Violence Essay

If we accept all of these caveats and consider the aetiology of domestic violence in general terms, a number of different authorities point to a number of different factors which appear to be significant in the genesis and perpetuation of the abusive and violent situation. Boyle suggests that controlling behaviour in the perpetrator is significant and Dearwater (S R et al. 1998) suggests a crescendo scenario starting from verbal abuse stemming from a failure of respect on the part of the perpetrator, which can then escalate into one of the other forms of controlling behaviour patterns. Controlling behaviour can be considered as economic control as well as physical control.

For a definitive and considered general statement on the issue we can look to the World Health Organisation who has defined violence as:

…the intentional use of physical force or power, threatened or actual…that either results in, or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation (WHO 1996). The Midwives Role in Domestic Violence Essay

If we consult the literature for an appreciation of the incidence of domestic violence, we immediately face the problem (quite apart from that of actual definition cited above) of knowing the extent of domestic violence that is unreported. Clearly we can cite figures that reflect the number of cases that are reported to the police or are suspected at the A&E departments across the country, as these are figures that are routinely collected and are in the public domain. Abbott (J et al. 1995), in trying to understand the degree of the problem, undertook a large cross sectional study and commented on the reluctance of many victims to disclose significant information. Their study (albeit American based) suggested that 11.7% of women who attended the A&E Depts. included in their study,  were attending because of either injuries or stress directly referable to domestic violence in one of its many forms. Of all the women seen in the A&E Depts., 2% were there as a direct result of physical trauma sustained  directly from an abusive relationship, and this particular study suggests a staggering 54.2% lifetime prevalence rate for domestic violence in the populations of women who were seen in the A&E Depts. during the period of the study. This may well reflect the comments made in the opening paragraph of this review that the degree of domestic violence is as much a factor of the culture of the perpetrator and definition of the act as much as any other factors. This is illustrated  by consideration of a comparison with a similarly constructed UK study (Boyle A A et al. 2003) which found that 1% of women attending the A&E Depts in the study were there as a direct result of direct physical violence and the same authors calculated the overall lifetime prevalence rate for domestic violence in this population to be in the region of 22%.   This second set of figures is more nearly in keeping with the majority of other studies in the area (viz. Dearwater S R et al. 1998).The Midwives Role in Domestic Violence Essay

A smaller Scottish study (Wright J et al. 1997) considered an A&E dept seeing 60,000 cases per year and found 19 cases of overt (incontrovertible) domestic violence in a two month period. Another factor which may be considered to be implicit in the term “domestic violence” is the fact that the violence is considered to have occurred in the home. This is not universally the case. A rather older study (Fothergill N et al. 1990) found that between 15% and 20% of cases of assault occurred at sites away from the victim’s home. One of the overriding factors that must be considered in any type of critical analysis of the figures is that part of the apparent disparity in both incidence and prevalence is due to the structure of the studies. There appears to be a distinct overrepresentation of victims of domestic violence in the populations that present to A&E Depts. If we compare these figures with those obtained from more community based studies such as the British Crime Survey (cited in Mirrlees-Black C 1999) we find that lifetime prevalence figures are in the region of 26% for women and 17% for men and annual prevalence figures in the same study are quoted as 5.9% and 4.9% respectively.

We have made mention of some of the demographic elements earlier. If we consider these in rather more detail, we can point to studies (Roberts G L et al. 1996) which suggest that, (again in a population of A&E Dept attenders), over 15% of men had experienced at least one episode of domestic violence in their lives and this was approximately half that of a similar group of women. Factors that were found to be independent risk factors for the risk of domestic violence include lack of education, alcohol misuse, unemployment, low income, and recreational drug use (Kyriacou D N et al. 1999).

In specific consideration of our investigation in the role of the midwife in the issue of domestic violence, we note that there was a widely reported study which suggested that being pregnant was also an independent risk factor for abuse (Gelles R J 1988). This was considered to be a landmark study in the area at the time of its publication, but we note that other reputable and carefully constructed studies have failed to replicate the original author’s findings. (McGrath M E et al. 1998. Other relevant factors include comparative youth as a risk factor and there are also studies that suggest that post-partum status carries a higher risk of domestic violence than does antenatal status. (Gazmararian J A et al. 1996). The same study also provides evidence to support the view that both the severity and the frequency of attacks of overt physical violence appears to escalate as pregnancy progresses and passes to the post natal period reaching a peak at between 6-9 months post partum.The Midwives Role in Domestic Violence Essay

In terms of identification of the potential victim of domestic violence the midwife (or other healthcare professional) should be alert for a number of signs and symptoms that have a high index of suspicion for domestic violence. (Staquet M J et al. 1998).  Different studies have identified different characteristics of the abused partner but there are a number of common factors which appear to be reasonably consistent throughout the major studies of the subject.

The most common consensus is that the victim will tend to demonstrate an increased usage of healthcare facilities. In general terms Bergman (B et al. 1991) is typical in this regard and documents an increased utilisation of all forms of medical care, most notably hospital admission which were found to be four times higher in this group than the admission rate in the general population.  even though we must accept that in the figure derived for the “general population” there will inevitably be an unknown, but probably significant, number of undetected cases of victims of domestic violence. Intuitive examination of the issue might suggest that there would be an increase in the usage of the psychiatric services and indeed, the same study points to a higher utilisation of facilities that are associated with alcoholism, depression and also deliberate self harm in the victims of domestic violence group. In terms of the index of suspicion for the visiting midwife, the authors suggest that women who present with multisystem, frequent and poorly defined complaints should be regarded as being the most likely to have an underlying problem with domestic violence, even they may not wish to overtly communicate this fact top the healthcare professional, it should be regarded as a significant warning sign.The Midwives Role in Domestic Violence Essay

Other studies point to other warning signs. We have already commented upon the likelihood of repeated attendance being associated with domestic violence, but interestingly, one study. (Spedding R L et al. 1999) suggested that the time of presentation was also significant. For reasons that the authors did not enlarge or speculate on they found that assaulted women were more likely to present between 6 pm and 6 am when compared to those with unintentional injuries.

There is considerable discussion and debate in the literature related to whether these traits and characteristics suggest a causal or resultant relationship between observed symptomatology and the situation of domestic violence. On an intuitive level one can postulate that being the victim of domestic violence or being in a long-term abusive relationship may be sufficient cause to present to a healthcare professional with depression, and could easily lead to episodes of deliberate self harm equally Wadman (M C et al. 1999) considers the possibility that the personality traits that can be frequently associated with both a depressive personality and also the tendency to deliberate self harm, may also “confer an increased risk of entering an abusive relationship”. Examination of the current literature on this element does not help us to reach any clearer view on the issue other than to allow us to present the fact that there is clearly a dichotomy of opinion on the subject.

In specific regard to issues surrounding pregnancy we can also note that there is evidence to suggest that violence can be specifically related to such issues. (CMO 2000). Of all the women who died in a three year period (‘97-’99) with a death related to pregnancy, 12% had reported domestic violence at some stage prior to their death. The study did not make any direct observation (because it couldn’t) of a direct link between domestic violence and the death.
Although not specifically in the direct province of the midwife, one can also consider the effects of domestic violence on other family members. Such studies are clearly difficult to construct and conduct as the element of denial and the element of secrecy will obviously be large and significant confounding factors in any investigation or statistical analysis. (Mohammed, D et al. 2003).The Midwives Role in Domestic Violence Essay

Studies such as that by Berrios (D C et al. 1991) shows strong circumstantial evidence that children who are brought up in situations with physically violent parents have a greater incidence of suffering direct physical abuse from either or both of their parents. We shall return to this point later, but observe that this knowledge puts a further obligation upon healthcare professionals in general to try to predict and detect domestic violence, not only from the point of view of the direct victims, but also from the viewpoint of the peripheral or indirect victims as well.

The psychopathology of the perpetrators (and to a lesser extent the victims) of domestic violence is examined in the thought provoking paper by Zink (T et al. 2004). This paper considers the features of medical management of the perpetrators, which is not particularly relevant to our considerations here. What is of  far greater relevance is the section of the paper where the authors consider the mechanisms whereby the offenders come to a position where they indulge in domestic violence. This gives the healthcare professional a useful insight into the possible dynamics of the situation. (Fawcett J 2005). The Midwives Role in Domestic Violence Essay

In terms of the victim coming to the stage where they feel that support and action is necessary, the authors identify a five stage model of change which is clearly heavily based on the trans theoretical model. (Prochaska  J O et al. 1992). They enumerate the five stages as :
pre-contemplation, contemplation, preparation, action, and maintenance.

As the patient considers their predicament, they will tend to oscillate or cycle through these stages often finding that they move repeatedly between the stages of contemplation, action and maintenance. (Prochaska J O et al. 1994)

This model of the  stages-of-change closely matches modifications in attitude and behaviour with the tools that are used by the individual when trying to alter his or her behaviour. Prochaska identified 10 tools that are cognitive-affective or behavioural activities which are relevant to these considerations. The cognitive-affective tools (including consciousness-raising, dramatic relief, self-re-evaluation) are used during precontemplation and contemplation. Behavioural tools however, are typically used in the action and maintenance stages. Using the right tool for each stage is important. Many of these changes are equally applicable to the psychopathology of the perpetrator who also appears to move through the same phases. The authors suggest that they tend to be more impulsive however, and the time spent in each stage may be very short indeed. In the light of our examination here, we should note that we can find no study that has examined the victim’s perception of the healthcare professional’s management of the situation with reference to the particular stage of the transition that they are in. Intuitively it would seem likely that the strategies that may be appropriate when the victim is in the contemplative stage are likely to have a different degree of effectiveness when employed in the action stage.

The authors reflect on the fact that there are a great many factors that may well be relevant in any one individual victim’s process of abuse management. This is the one area where the victim of domestic violence has a degree of control as to just how they respond to abusive behaviour. It therefore appears to be very important, from the viewpoint of effective management, that the healthcare professional involved maximises any degree of positive resolve with an empathetic exploration of the relevant issues as far as they are perceived by the patient themselves. The Midwives Role in Domestic Violence Essay

The role of the midwife is, in part, that of Health Promotion facilitator. (Hewison, A. 2004). The midwife has traditionally taken an active role in areas such as teenage pregnancy, smoking cessation, drug awareness. (Ramsey J et al. 2002)   Perhaps we should now consider adding to that list domestic violence as well. We note that the term, and indeed the concept, of Health Promotion, should be synonymous with work that encourages healthy behaviour in the widest possible sense of the word and is therefore complimentary to the more traditional concepts of the healthcare professionals managing disease and ill health. The paper by Beldon (A et al. 2005) considers this issue from the health promotion viewpoint. The authors point to the midwife as being a pivotal professional in terms of a healthcare professional contact for many women in their younger adult lives, when domestic violence is at its peak incidence and also when childbearing is at its most prevalent.

The authors assert that the concept of empowerment and education (Howe and  Anderson  2003) should be at the forefront of the midwife’s agenda and this will act as a bridge to build up trust and a working relationship that can help to detect domestic violence when it occurs and then to help support the victim with appropriate intervention and agency notification.  Although as a concept paper, this is eloquently presented and rationally considered, one is left with the thoughts that a more critical analysis of the message of this paper could be that, as altruistic as these particular aims are, in the current structure of the NHS it is difficult to see how a midwife could actually embrace all of the different concepts and activities that this paper suggests. This is not meant to imply that one should not aspire to achieve all that is suggested, but may indicate the fact that in order to achieve a more public health orientated service, then more protected time may be required to allow the midwife to fulfil all of these functions. In fairness, the paper includes a comment that appears to recognise the fact that change is necessary by exhorting midwives in general to “seek to respond positively to service changes to achieve the goal of multidisciplinary, non-hierarchical patient-centred services. In facilitating change midwives should seek to use their influence to the benefit of the pregnant woman.”

The paper by Taket (A et al. 2003) is another overview concept paper which rehearses many of the arguments that we have presented elsewhere in this review, but it is noteworthy for the fact that it devotes a considerable amount of energy in the examination of the role of domestic violence on the children and points to the fact that the midwife may have her suspicions aroused by the behaviour patterns of affected children even if she has not considered the possibility of domestic violence in relation to the mother’s behaviour or presentation.The Midwives Role in Domestic Violence Essay

The authors point to the fact that some studies (viz.Humphreys C et al. 2002) suggest that  children who are living in a house where domestic violence is active are 30 – 60% more likely to experience child abuse (the paper does not specify physical abuse, but abuse in the wider sense). They are more likely to present with neurotic types of problems including sleep disturbance, poor school performance, emotional detachment, stammering, suicide attempts, and aggressive and disruptive behaviour. The relevance of any of these factors should be regarded as firstly an indicator for the midwife to actively consider making direct, but sensitive, enquiries in relation to domestic violence, as well as making sure that the affected children are referred to the appropriate agency in order that these traits may be actively investigated and treated. The paper also makes the very valid and fundamental point that children who witness domestic violence learn to accept that violence is an appropriate mechanism for resolving conflict and that these behaviour patterns are likely to manifest themselves in these individuals as they grow into adulthood. (Hague G et al. 1998). They make no comment about the intuitive possibility that children who suffer or observe domestic violence may also have a higher incidence of neurotic traits in adult life.

If we now consider specific papers that target the phenomenon of domestic violence in specific relation to pregnancy, we can start with the paper by Mezey (G C et al. 1997). This is an attempt to provide an overview of the area, which it certainly does, but it has to be observed that the papers that it cites, although undoubtedly worthy, are not particularly representative of the whole spectrum of the available literature on the subject. One of the reasons that we have presented a long preamble prior to reviewing specific papers, is the fact that we have been at pains to consider a wide spectrum of authoritative opinion in this area. The comments that the paper makes that domestic violence is reported by up to 25% of women in the Britain, is demonstrably misleading. The paper it cites for this bold statement is the Mooney paper (Mooney J 1993). The major stumbling block here is that the paper itself is a well constructed study, but the entry cohort was women known to the social services in Islington. It is clearly a major error of judgement to try to extrapolate this figure to be representative of the women of Britain in general. There are a number of similar methodological errors in the paper but the reason that we have selected it for inclusion here is the fact that it specifically examines the literature of domestic violence relating to pregnancy. In addition to many of the points that we have already raised in terms of the demography and aetiology of domestic violence, the paper cites convincing evidence that the risk of domestic violence is enhanced by pregnancy with severe attacks being the most common in the post-partum period. It is both interesting, and possibly significant, to note that one paper that is repeatedly cited is the Hilberman paper of 1978. (Hilberman E et al. 1978). This is a particularly interesting paper as it is written from the author’s viewpoint that women who suffer domestic violence are often compliant victims. The Midwives Role in Domestic Violence Essay. It puts forward anecdotal evidence to suggest that some women in abusive relationships will often actually try to become pregnant in an attempt to protect themselves from further attack. The authors cite the fact that women who are both pregnant and victims of domestic violence, are much more likely to describe their pregnancy as unplanned and unwanted. It seems clear that any analytical assessment of these two concepts would suggest that they are mutually exclusive. In any event it would appear that the situation, if contrived, is more likely to generate further violence than to protect against it. The authors do not specifically suggest the hypothesis, but it would seem to support those who argue that certain women are actually more secure in an abusive relationship. (Gazmararian J A et al. 1995). We can make no comment on this point other than it seems to be made in the absence of any convincing evidence base.

A very significant feature of this paper, and certainly one that does appear to have a far more secure evidence base than some of the other statements that we have examined, is the section which deals with the complications of domestic violence in the pregnant state. The paper makes the self evident, but yet very relevant, observation that domestic violence during pregnancy places in jeopardy the health and safety of two individuals rather than the one that would be the case in the non-pregnant state. It points to the fact that domestic violence is associated with an increased risk of “miscarriage, premature birth, low birth weight, chorioamnionitis, foetal injury, and foetal death”. It cites a number of sources for this information (including the Hilberman paper) but the quote is largely lifted directly from the entirely reputable Berenson paper (Berenson A B et al. 1994). The difficulty in producing statistically significant and reliable data to back up the degree of risk is considerable because, as Berenson points out, the very factors that are known to be associated with domestic violence, such as increased drug and alcohol use together with an increased incidence of smoking, are also the very factors that are associated with increased foetal morbidity and mortality in any event. (Webster J et al. 1996).The Midwives Role in Domestic Violence Essay

Other significant factors are also explored in this particular section of the paper including the fact that the authors suggest that the foetus may be indirectly harmed by the fact that abused women may be (either directly or indirectly) prevented from seeking adequate ante-natal and post-natal advice and care by their abusive partners. (Norton L B et al. 1995). We shall return to a different significance of this point later.

Interestingly, the authors open up a discussion on the current status of the health care policies in the UK in relation to domestic violence. They point to the fact that the recent changes in both the practice of obstetrics and midwifery (which are said to enhance the ability of the healthcare professionals to provide empowerment and education for the pregnant women and to “demedicalise child birth” (authors term)), are the very changes that may have reduced the possibility of effective intervention. This is a bold statement, as it cites, for support, the fact that the “traditional refuge of the women-only status of the antenatal wards and the labour suite is disappearing”. it points to the fact that the antenatal clinics are noisy and busy places where a woman is less likely to share her problems with the healthcare professionals particularly if, in the words of the authors, they may be considered difficult, shameful, and risky. They do make a very valid observation that the era of hand held patient notes is indeed a counterproductive element simply because confidential documentation is recorded in a situation where it is no longer confidential and available to all who handle the notes. this can clearly be the abusive spouse if the victim is in a particularly controlling relationship. The paper observes that:

There should be greater awareness of the problem, improved identification techniques, and education about available social and legal interventions and the importance of liaison between agencies.The Midwives Role in Domestic Violence Essay

Sadly it does not make any suggestion to effect such changes.

If we consider the question of screening for domestic violence and the issues of how should the midwife most effectively utilise her time in this regard, we can consider the detailed paper by Clarke (K A et al. 2000) which specifically addresses the issue in great detail. One point that has not been previously raised in this context is that a past history of abuse in the post partum period in a previous pregnancy is associated with a 90% risk of abuse during a current pregnancy. (Stewart D E 1994). Interestingly the paper does not specify that the victim has to be with the same partner for this statistic to apply. This could, of course be an oversight, but if it is genuinely true for any partner, then this fact does add credence to the point raised earlier, that some women do tend to become selectively involved in abusive relationships.

The paper starts with the preamble of the at risk groups which we have rehearsed above and therefore will not repeat. The paper makes the comment that even taking into account all of the available strong risk factors, there is still a large cohort of women who are either abused or subject to domestic violence and are not suspected or detected by the healthcare professionals. They suggest that the midwife is ideally placed to screen for less obvious markers and indices that may allow for more cases of domestic violence to be identified, assessed and referred to appropriate intervention agencies. The authors therefore build a case for universal screening for partner violence to be a normal part of ante-natal care. In order to provide a secure evidence base for this case, the authors cite papers such as those by Covington and Wiist (Covington D L et al. 1997) (Wiist W H et al. 1999).

The Wiist paper details the American experience of ante-natal screening and both point to the fact that screening can significantly increase the prevalence of disclosure. Other papers are cited in support of the contention that abused women are actually relieved to be empowered and invited to discuss their problems with domestic violence and are happy to be “given permission” to speak openly about it. (Gerbert B et al. 1999). The authors also point to the fact that although healthcare professionals in the field of obstetrics and gynaecology are more likely to screen for partner violence than many other specialties, there is evidence that this specifically is not the case in the ante-natal clinics. While this may be true, we note that the studies cited all rely exclusively on information that is obtained from providers and not directly from the patients. We can therefore only hazard a guess as to the degree of transferable validity that the results impart.

The Clarke paper then details their study which considered a qualitative assessment of those women who were screened for domestic violence contrasted against those who were not. The entry cohort was impressive with over 2,500 women responding to the study. We will not discuss the methodology of the study in detail, as it is set out in extraordinary detail in the paper itself. But the significant findings do merit further discussion. Factors which triggered healthcare professionals to ask screening questions were found to include being unmarried, those with a poor education and being from an ethnic minority. Unemployment was three times more likely to result in questions relating to domestic violence than being employed and being on benefit produced similar odds. The other significant factor in screening was to be under the age of 20 yrs.

Despite the observations that we have made elsewhere in this review about partner violence being a salient factor in the ability of the expectant mother to access appropriate ante-natal care, in this study it was apparent that those mothers who had fewer attendances at the ante-natal clinic were less likely to receive screening than those who came regularly. Specifically the study found that those women who did not receive any ante-natal care in the first trimester had twice the odds of reporting a violent relationship when eventually questioned.The Midwives Role in Domestic Violence Essay