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On successfully completing this topic, you will be able to:
appreciate the incidence of domestic abuse
understand the implications for the woman and fetus during pregnancy and in the postnatal period
plan to identify cases and familiarise yourself with local support services.
Introduction
Domestic abuse is a major public health concern that threatens the health, emotional well- being and lives of women and their families.
Domestic abuse is defined, by the Department of Health,1 as, ‘Any incident of threatening behaviour or abuse (psychological, physical, sexual, financial or emotional) between adults who are, or have been, intimate partners or family members, regardless of gender or sexuality.’ Women are more likely to be victims in heterosexual relationships (90%). Domestic abuse affects all social classes, all ethnic groups, occurs worldwide and affects all age groups. The broader definition allows for forced marriage, honour killings and female genital mutilation to be recognised as being part of the issue.
Scale of the problem
One in three women experiences domestic abuse at some point in their lives.
One in ten women will have experienced domestic abuse in the past year.
Over one million domestic abuse incidents are recorded by the police each year.
30% of domestic abuse starts in pregnancy.
40% of women who are murdered are killed by a current or ex-partner.
Domestic abuse is more common than violence in the street or a public house.
In the 2006–08 CMACE – Saving Mothers’ Lives – it was reported that 11 women were murdered by their partners during, or soon after, pregnancy.2 A total of 34 women, who died from other causes, were known to be victims of, or had self-reported, domestic abuse.
What keeps women in abusive relationships?
To outsiders it seems almost bizarre that anyone would stay within an abusive relationship, but nonetheless they do. The reasons for staying are often multiple:
Fear: If she leaves, she is afraid that she or other family members will experience more abuse or possibly be killed.
Financial: Control of her resources by her abuser.
Family: Pressures to stay with the abuser.
Father: Wanting a father figure for her children. Faith: That she places in a religious doctrine. Forgiveness: The abuser is often contrite.
Fatigue: From living under high and constant stress and erosion of self-esteem.
Domestic abuse and pregnancy
The incidence of domestic abuse in pregnancy is reported as being 0.9–20.1%. Domestic abuse often begins or escalates during pregnancy, or in some cases, it commences in the puerperium. The risk of moderate-to-severe abuse appears to be greatest in the postpartum period. Women suffering physical abuse are at increased risk for miscarriage, premature labour, placental abruption, low birthweight infants, fetal injury and intrauterine fetal death. Often, as a result of the abuse, women are 15 times more likely to misuse alcohol, nine times more likely to misuse drugs, three times more likely to be clinically depressed and five times more likely to attempt suicide. These all obviously have implications for both the mother and fetus.
Classically, injuries towards the pregnant abdomen, genitals and breasts are seen in pregnancy. However, the injuries can be multiple affecting any part of the woman’s body. Campbell reported that 9.5% of women reported sexual abuse and 13.9% were raped by their partners.
Recognising domestic violence in pregnancy
Women who are being abused often book late and may be poor attenders. Their partners may not give them enough money to get to the hospital. Alternatively, they may attend repeatedly with trivial symptoms and appear reluctant to be discharged home. If the partner accompanies the woman, he may be constantly present not allowing for private discussion. The woman may seem reluctant to speak in front of, or contradict, her partner.
Any signs of abuse on the woman’s body will be minimised. As with child abuse, the mechanism of injury often does not fit with the apparent injury. There may be untended injuries of different ages or the late presentation of injuries. A history of behavioural problems or abuse in the children may be indicative. Often the patient will give a history of psychiatric illness.
Diagnosing domestic abuse
As domestic abuse often begins or escalates during pregnancy, it is essential that we, as obstetricians and midwives, routinely ask women whether they are subject to mistreatment. Abusive pregnancies are high risk and domestic abuse is much more prevalent than most other complications of pregnancy, such as pre-eclampsia or gestational diabetes mellitus. Standard questions should therefore be included, in the same way as we would ask about medical disorders, smoking or alcohol use. Systematic multiple assessment protocols lead to increased detection and reporting of abuse during pregnancy. The mnemonic RADAR was developed, by the Massachusetts Medical Society, as a tool to guide enquiry about domestic abuse.3
- R
- A
Ask direct questions
- D
Document your findings
- A
Assess safety
- R
Review options and choices
Health professionals should be given appropriate training and education to improve awareness. Questions should be asked in a nonjudgemental, respectful, supportive manner. Obstetricians and midwives should be aware of what help is available should a woman request help. Questions, such as the following, may allow the woman to disclose the fact that she is subject to violence:
I have noticed you have a number of bruises. Did someone hit you? You seemed frightened by your partner. Has he ever hurt you?
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