Clinical Practice Guidelines Antenatal care - Module I

7.7 Domestic violence

Page last updated: 02 April 2013

Antenatal care provides an opportunity to ask women about exposure to violence especially at home or in their family. Asking questions may assist women to disclose their experiences of violence to health professionals and enable access to additional support and care, including community, legal and police support services.

7.7.1 Background

Domestic violence (also referred to as intimate partner violence or family violence) occurs when one person attempts to control and dominate another in an intimate or familial relationship. Numerous studies have demonstrated that domestic violence is primarily perpetrated against women and children. Domestic violence manifests in a variety of forms, including physical, psychological, economic, social and sexual abuse. Domestic violence is relatively common during pregnancy. The frequency and severity of violence initiated by male partners against women may be higher during pregnancy (Burch & Gallup 2004; Martin et al 2004) but the evidence is not consistent (Campbell et al 2004; Walsh 2008).

Domestic violence in Australia

While differing definitions of domestic violence are used in studies, the following points give an indication of its prevalence.
  • In Australia in 2005, 5.8% of women had experienced domestic violence in the previous 12 months (ABS 2006).
  • Estimates from general populations are that between 1 and 20% of women experience domestic violence during pregnancy or after the birth (Taft 2002).
  • In 2005, among Australian women who had ever experienced violence by a previous partner, 36% reported that this occurred when they were pregnant and 17% experienced violence for the first time when they were pregnant (ABS 2006).
  • In an Australian survey of 400 pregnant women, 20% had experienced violence during pregnancy (Walsh 2008).
  • Based on information from the Supported Accommodation Assistance Program, women in rural and remote areas are more likely to experience domestic violence than those in metropolitan areas. In 2004–05, the rates of domestic violence-related support provided per 1,000 population were highest in very remote areas (16.7), followed by remote areas (12.8), outer regional areas (3.4), inner regional areas (2.6) and major cities (2.0) (DTRS 2006).
  • Aboriginal and Torres Strait Islander people are much more likely than non-Indigenous people to experience domestic violence and to be hospitalised for injuries arising from assault (AHMAC 2006). In 2002, 23% of Aboriginal women aged over 15 years reported an experience of physical violence or threatened violence in the previous 12 months (ABS & AIHW 2005).

Risks associated with domestic violence in pregnancy

  • Violence poses serious health risks to pregnant women (including breast and genital injury, miscarriage, antepartum haemorrhage and infection, blunt or penetrating abdominal trauma and death) and babies (including fetal fractures, low birth weight, injury, suppressed immune system) (Walsh 2008).
  • Young women exposed to violence are more likely to have a miscarriage, stillbirth, premature birth or termination of pregnancy than other young women (Taft et al 2004).
  • Women exposed to violence during pregnancy are more likely to develop depression in the postnatal period (Bacchus et al 2003; Mezey et al 2005).

7.7.2 Assessing for domestic violence

The NICE guidelines note that health professionals need to be alert to the signs and symptoms of violence and give women the opportunity to disclose in an environment in which they feel secure. Canadian guidelines recommend that queries about violence be included as part of antenatal care (Cherniak et al 2005). The American College of Obstetricians and Gynecologists recommends assessing all women for domestic violence at the first antenatal visit and at least once per trimester (ACOG 2006). Routine questioning of women about domestic violence has been progressively introduced in antenatal services in some jurisdictions (eg Spangar 2007) and many State and Territories have guidelines that recommend that health care professionals routinely ask all pregnant women about their experiences of abuse (eg VCCC VM 2006).

Summary of the evidence

Acceptability to women

Most women find it acceptable for health professionals to ask them about experiences of domestic violence (Keeling & Birch 2004; Renker & Tonkin 2006; Roelens 2010). Some women may not disclose to health professionals (Bacchus et al 2003) unless asked directly (Hegarty et al 2007; Roelens et al 2008). Screening or assessment tools may increase the identification of domestic violence (Moonesinghe et al 2004; Kataoka et al 2004; Webster & Holt 2004; Ameh et al 2008; O’Reilly et al 2010) as they provide a series of structured questions asked of all women. The presence of the woman’s partner may be a barrier to disclosure of domestic violence (Taft 2002), so women should be seen alone at least once during pregnancy, particularly during the first antenatal visit (Stenson et al 2005; Salmon et al 2006).

Recommendation - Grade B

8. At the first antenatal visit, explain to all women that asking about domestic violence is a routine part of antenatal care and enquire about each woman’s exposure to domestic violence.

Consensus-based recommendation

vi. Ask about domestic violence when alone with the woman, tailoring the approach to her individual situation and your own skills and experience (eg use open-ended questions about her perception of safety at home or use an assessment tool).

Acceptability to health professionals

While routine enquiry about domestic violence is largely acceptable to health professionals (Morgan 2003; Protheroe et al 2004; Barnett 2005; Lazenbatt et al 2005; Stenson et al 2005; Hindin 2006; Salmon et al 2006; Lazenbatt et al 2009; Lazenbatt 2010), many are not comfortable with making such enquiry (Baird 2005; Gunn et al 2006; Herzig et al 2006; Edin et al 2010) feeling that they lack relevant knowledge and training to respond effectively if domestic violence is identified (Denham 2003; Lazenbatt 2010). Language and cultural barriers and fear of distressing the woman may also reduce levels of enquiry (Jeanjot et al 2008). Personal experiences of domestic violence may also affect health professionals’ ability to enquire about domestic violence (Morgan 2003).

Training and support in discussing and responding to domestic violence provides health professionals with the knowledge and skills they need to respond effectively (Bacchus et al 2003; Denham 2003; Mezey et al 2003; Morgan 2003; Protheroe et al 2004; Baird 2005; Barnett 2005; Torres-Vitolas et al 2010).

Consensus-based recommendation

vii. Be aware that training programs improve the confidence and competency of health professionals in identifying and caring for women experiencing domestic violence.

Interventions

Brief psycho-behavioural interventions may improve domestic violence and pregnancy outcomes (Kiely et al 2010). Counselling sessions and advocacy programs for women experiencing domestic violence are effective in reducing domestic violence (Kataoka et al 2004).

Discussing and responding to domestic violence

Discussion of domestic violence requires rapport between the health professional and the woman. Women experiencing abuse may not speak up when the subject is first raised but may choose to open up later when they feel sufficient trust and confidence in the health professional, possibly at a subsequent visit. It is important for health professionals to enquire about domestic violence in a sensitive manner and provide a response that takes into account the complexity of women’s needs (Bacchus et al 2003).

If a woman discloses that she is experiencing domestic violence, an immediate response is needed, with the woman’s safety a primary consideration.

Table 7.5: Key considerations in discussing and responding to domestic violence

    Use direct or indirect questions or an assessment tool, depending on clinical experience and the perceived level of trust in the relationship
    Explain that the woman’s responses will be kept confidential
    Actively listen to what the woman tells you
    Do not blame or judge the woman or her partner
    Inform the woman that she is not alone, there are other women experiencing domestic violence
    Affirm that the woman has made an important step by discussing her experiences
    Reinforce that domestic violence is against the law and that the woman has a choice not to live with the violence
    Reinforce that the woman should not self-blame
    Affirm to the woman that the decision to discuss domestic violence is a major step to enhance her safety
    Assist the woman to assess her safety and that of children in her care
    Discuss options for safe temporary accommodation if needed and available (eg women’s refuge, safe house, family or friends, hospital)
    Encourage the woman to access specialist support services (eg woman’s health centre, social worker, counsellor, mental health service)
    Inform the woman of her legal right to protection and provide information on legal support services
    Inform the woman that disclosure of domestic violence may require further discussion and possible reporting in relation to child protection issues8
    Be aware of available security supports that can be used to protect the woman and yourself if needed
    Report any incidents of violence according to organisational policy and jurisdictional legislation1
Sources: Adapted from Eastern Perth Public and Community Health Unit (2001) and NHMRC (2002).

Health professionals with limited experience in responding to domestic violence can enhance their practice by:
  • seeking training and support (eg clinical supervision) where available (see Section 7.7.4);
  • planning a response to disclosure of violence, including considerations of safety, confidentiality, sensitivity and informed support; and
  • being familiar with specialised counselling services, emergency housing agencies and legal support services in the local area.

Considerations in Aboriginal and Torres Strait Islander communities

Domestic violence has a significant impact in some Aboriginal and Torres Strait Islander communities. Historical circumstances, the loss of land and traditional culture, the disempowerment of traditional elders, breakdown of Aboriginal law and community kinship systems, entrenched poverty and racism are factors underlying the use of violence in Aboriginal and Torres Strait Islander communities (Mulroney 2003). Intergenerational effects of institutionalisation, oppression and child removal policies, have also resulted in ongoing trauma, loss and unresolved grief and contributed to a range of health and wellbeing problems and issues, including violence (NACCHO 2006).

Aboriginal and Torres Strait Islander women may choose not to disclose domestic violence. Factors that may influence a woman’s decision to disclose include:
  • mistrust of police, the law and other state institutions (Heenan 2004);
  • the implications of reporting (eg fear of the woman’s partner being imprisoned in the context of the disproportionate rates of Aboriginal men in prison and high rates of Aboriginal deaths in custody) (Heenan 2004);
  • the cultural competence of the health professional involved; and
  • kinship systems (eg in intrafamilial violence there may be a need to cut ties with the family following disclosure) (Cox 2008).
These factors also influence responses to disclosure of domestic violence by Aboriginal and Torres Strait Islander women. Confidentiality and privacy are important considerations. Women should be asked about who they would like involved in their care and offered a clear choice about referral options, including both Aboriginal-specific services and mainstream services.

Practice point

i. Responses to assisting Aboriginal and Torres Strait Islander women who are experiencing domestic violence need to be appropriate to the woman and her community. Health professionals should be aware of family and community structures and support.

Approaches to addressing factors underlying domestic violence in Aboriginal and Torres Strait Islander communities are beyond the scope of these Guidelines. Some relevant resources are identified in Section 7.7.4.

Considerations in rural and remote areas

Assisting women experiencing domestic violence in rural and remote areas may be complex due to:
  • limited resources to call on for advice or an immediate response;
  • limited specialised services to assist in the woman’s ongoing care;
  • difficulties ensuring confidentiality in smaller towns and communities; and
  • difficulties when the health professional has a relationship with the woman (eg through family, kinship or friendship), particularly if mandatory reporting is required.

Practice point

j. Health professionals should be aware of resources for domestic violence services in their community that can be called for urgent assistance. This may include local safe houses or the Strong Women Workers in their community.

Considerations beyond the first trimester
Multiple assessments for domestic violence during pregnancy increase reporting (O’Reilly et al 2010).

7.7.3 Practice summary — assessing for domestic violence

When — At the first antenatal visit
Who — Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander health worker; multicultural health worker
  • Discuss assessment for domestic violence — Explain that enquiry about domestic violence is a routine part of antenatal care and that it aims to identify women who would like assistance. Explain confidentiality and provide opportunities for the woman to discuss domestic violence in privacy (eg without her partner present).
  • Take a holistic approach — If a woman affirms that she is experiencing domestic violence, other considerations include counselling and ongoing support. The safety of the woman and children in her care should be assessed and referral to other services (eg police, emergency housing, community services) made as required.
  • Learn about locally available support services — Available support services for women who are experiencing domestic violence will vary by location.
  • Document the discussion — Document in the medical record any evidence of injuries, treatment provided because of injuries, referrals made and any information the woman provides. If woman-held records are used, the information included in these should be limited and more detailed records kept at the health service.
  • Seek support — Depending on your skills and experience in discussing domestic violence with women and assisting them if they are experiencing domestic violence, seek advice and support through training programs, clinical supervision, mentoring and/or helplines.
  • Be aware of relevant legislation — Each State and Territory has requirements about reporting violence as set out in its legislation.

7.7.4 Resources

Training

DiVeRT - Domestic Violence Response Training. Free face-to-face or online training for health professionals through Lifeline.
www.lifeline.org.au/About-Lifeline/Learning (This website link was valid at the time of submission) ---Development/DiVeRT---Domestic-Violence-Response-Training/DiVeRT---Domestic-Violence-Response-Training-for-Health-Professionals

Responding Appropriately to Domestic Violence Online Generic Resource Package. The University Department of Rural Health, Tasmania. For more information please visit University of Tasmania website.

Guidance

Family Violence Risk Assessment and Risk Management. Identifying Family Violence. Maternal and Child Nurses’ Training Handbook. An initiative of the Victorian Government Family Violence Reform program developed by Domestic Violence Resource Centre (Victoria) Swinburne University of Technology. For more information please visit Swinburne University of Technology website

Eastern Perth Public and Community Health Unit (2001) Responding to Family & Domestic Violence A Guide for Health Care Professionals in Western Australia. Perth: Department of Health, Government of Western Australia. For more information please visit Department of Health, WA.

NHMRC (2002) When It’s Right in Front of You. Assisting Health Care Workers to Manage the Effects of Violence in Rural and Remote Australia. Canberra: National Health and Medical Research Council. For more information please visit National Health and Medical Research Council website.

WSDH (2008) Domestic Violence and Pregnancy: Guidelines for Screening and Referral. Olympia: Washing State Department of Health. http://www.doh.wa.gov/cfh/mch/documents/DVPgGuide82008.pdf (This website link was valid at the time of submission)

Assessment tools

Robinson E & Moloney L (2010) Family Violence. Towards a Holistic Approach to Screening and Risk Assessment in Family Support Services. Australian Family Relationships Clearinghouse. Canberra: Australian Institute of Family Studies.

7.7.5 References

ABS (2006) Personal Safety Survey. ABS Cat No 4906.0. Canberra: Australian Bureau of Statistics.

ABS & AIHW (2005) The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples 2005. ABS Cat No 4704.0. Australian Bureau of Statistics and Australian Institute of Health and Welfare. Commonwealth of Australia.

ACOG (2006) ACOG Committee Opinion No. 343: psychosocial risk factors: perinatal screening and intervention. American College of Obstetricians and Gynecologists Committee on Health Care for Undeserved Women. Obstet Gynecol 108(2): 469–77.

AHMAC (2006) Aboriginal and Torres Strait Islander Health Performance Framework Report 2006. Canberra: Australian Health Ministers’ Advisory Council.

Ameh N, Shittu SO, Abdul MA (2008) Risk scoring for domestic violence in pregnancy. Niger J Clin Pract 11(1): 18–21.

Bacchus L, Mezey G, Bewley S (2003) Experiences of seeking help from health professionals in a sample of women who experienced domestic violence. Health Soc Care Comm 11(1): 10–18.

Baird K (2005) Domestic violence: learning to ask the question. Practis Midwife 8(11): 18–22.

Barnett, C (2005) Exploring midwives’ attitudes to domestic violence screening. Brit J Midwifery 13(11): 702–05.

Burch RL & Gallup GG (2004) Pregnancy as a stimulus for domestic violence. J Fam Violence 19(4): 243–47.

Campbell J, Garcia-Moreno C, Sharps P (2004) Abuse during pregnancy in industrialized and developing countries. Violence Against Women 10(7): 770–89.

Cherniak D, Grant L, Mason R et al (2005) Intimate partner violence consensus statement. Clinical Practice Guidelines No 157. J Obstet Gynaecol Can 27(4): 365–418.

Cox D (2008) Working with Indigenous survivors of sexual assault. ACSSA Wrap No.8. Melbourne: Australian Centre for the Study of Sexual Assault, Australian Institute of Family Studies.

Denham SA (2003) Describing abuse of pregnant women and their healthcare workers in rural Appalachia. Am J Matern Child Nurs 28(4): 264–69.

DTRS (2006) About Australia’s Regions August 2006. Canberra: Department of Transport and Regional Services.

Eastern Perth Public and Community Health Unit (2001) Responding to Family & Domestic Violence A Guide for Health Care Professionals in Western Australia. Perth: Department of Health, Government of Western Australia.

Edin KE, Dahlgren L, Lalos A et al (2010) “Keeping up a front”: narratives about intimate partner violence, pregnancy, and antenatal care. Violence Against Women 16(2): 189–206.

Gunn J, Hegarty K, Nagle C et al (2006) Putting woman-centered care into practice: A new (ANEW) approach to psychosocial risk assessment during pregnancy. Birth 33(1): 46–55.

Heenan M (2004) Just keeping the peace: a reluctance to respond to male partner sexual violence. ACSSA Issues No.1. Melbourne: Australian Centre for the Study of Sexual Assault, Australian Institute of Family Studies.

Hegarty K, Brown S, Gunn J et al (2007) Women’s views and outcomes of an educational intervention designed to enhance psychosocial support for women during pregnancy. Birth 34(2): 155–63.

Herzig K, Huynh D, Gilbert P et al (2006) Comparing Prenatal Providers’ Approaches to Four Different Risks: Alcohol,Tobacco, Drugs, and Domestic Violence. Women Health 43(3): 83–101.

Hindin PK (2006) Intimate partner violence screening practices of certified nurse-midwives. J Midwifery Women’s Health 51(3): 216–21.

Jeanjot I, Barlow P, Rozenberg S (2008) Domestic violence during pregnancy: Survey of patients and healthcare providers. J Women’s Health 17(4): 557–67.

Kataoka Y, Yaju Y, Eto H et al (2004) Screening of domestic violence against women in the perinatal setting: A systematic review. Japan J Nursing Sci 1(2): 77–86.

Keeling J & Birch L (2004) Asking pregnant women about domestic abuse. Brit J Midwifery 12(12): 746–49.

Kiely M, El-Mohandes AA, El-Khorazaty MN et al (2010) An integrated intervention to reduce intimate partner violence in pregnancy: a randomized controlled trial. Obstet Gynecol 115(2 Pt 1): 273–83.

Lazenbatt A (2010) Safeguarding children and public health: Midwives’ responsibilities. Perspect Pub Health 130(3): 118–126.

Lazenbatt A, Taylor J, Cree L (2009) A healthy settings framework: an evaluation and comparison of midwives’ responses to addressing domestic violence. Midwifery 25(6): 622–36.

Lazenbatt A, Thompson-Cree ME, McMurray F (2005) The use of exploratory factor analysis in evaluating midwives’ attitudes and stereotypical myths related to the identification and management of domestic violence in practice. Midwifery 21(4): 322–34.

Martin SL, Harris-Britt A, Li Y et al (2004) Changes in intimate partner violence during pregnancy. J Fam Violence 19(4): 201–10.

Mezey G, Bacchus L, Bewley S (2005) Domestic violence, lifetime trauma and psychological health of childbearing women. Brit J Obstet Gynaecol 112(2): 197–204.

Mezey G, Bacchus L, Haworth A et al (2003) Midwives’ perceptions and experiences of routine enquiry for domestic violence. Brit J Obstet Gynaecol 110(8): 744–52.

Moonesinghe LN, Rajapaksa LC, Samarasinghe G (2004) Development of a screening instrument to detect physical abuse and its use in a cohort of pregnant women in Sri Lanka. Asia-Pacific J Pub Health 16(2): 138–44.

Morgan JE (2003) Knowledge and experience of domestic violence. Brit J Midwifery 11(12): 741–47.

Mulroney J (2003) Australian Statistics on Domestic Violence. Sydney: Australian Domestic and Family Violence Clearinghouse.

NACCHO (2006) What’s Needed to Improve Child Abuse/Family Violence in a Social and Emotional Well Being Framework in Aboriginal Communities. Canberra: National Aboriginal Community Controlled Health Organisation.

NHMRC (2002) When It’s Right in Front of You. Assisting Health Care Workers to Manage the Effects of Violence in Rural and Remote Australia. Canberra: National Health and Medical Research Council.

O’Reilly R, Beale B, Gillies D (2010) Screening and intervention for domestic violence during pregnancy care: A systematic review. Trauma Violence Abuse 11(4): 190–201.

Protheroe L, Green J, Spiby H (2004) An interview study of the impact of domestic violence training on midwives. Midwifery 20(1): 94–103.

Renker PR & Tonkin P (2006) Women’s views of prenatal violence screening: acceptability and confidentiality issues.Obstet Gynecol 107(2 Pt 1): 348–54.

Roelens K (2010) Intimate partner violence. The gynaecologist’s perspective. Verh K Acad Geneeskd Belg 72(1–2): 17–40.

Roelens K, Verstraelen H, Van Egmond K et al (2008) Disclosure and health-seeking behaviour following intimate partner violence before and during pregnancy in Flanders, Belgium: a survey surveillance study. Eur J Obstet Gynecol Reprod Biol 137(1): 37–42.

Salmon D, Murphy S, Baird K et al (2006) An evaluation of the effectiveness of an educational programme promoting the introduction of routine antenatal enquiry for domestic violence. Midwifery 22(1): 6–14.

Spangar JM (2007) The NSW Health routine screening for domestic violence program. NSW Pub Health Bull 18(6): 86–89.

Stenson K, Sidenvall B, Heimer G (2005) Midwives’ experiences of routine antenatal questioning relating to men’s violence against women. Midwifery 21(4): 311–21.

Taft A (2002) Violence Against Women in Pregnancy and After Childbirth: Current Knowledge and Issues in Health Care Responses. Australian Domestic and Family Violence Clearinghouse Issues Paper 6.

Taft A, Watson LF, Lee C (2004) Violence against young Australian women and association with reproductive events: A cross-sectional analysis of a national population sample. Aust NZ J Pub Health 28(4): 324–29.

Torres-Vitolas C, Bacchus LJ, Aston G (2010) A comparison of the training needs of maternity and sexual health professionals in a London teaching hospital with regards to routine enquiry for domestic abuse. Public Health 124(8): 472–78.

VCCCVM (2006) Management of the Whole Family when Intimate Partner Violence is Present: Guidelines for Primary Care Physicians. Victorian Community Council on Crime and Violence Management. Melbourne: Victorian Department of Justice.

Walsh D (2008) The hidden experience of violence during pregnancy: a study of 400 pregnant Australian women. Aust J Primary Health 14(1): 97–105.

Webster J & Holt V (2004) Screening for partner violence: direct questioning or self-report? Obstet Gynecol 103(2): 299–303.

1 The legislation around mandatory reporting to police and child protection in relation to disclosure of domestic violence varies across Australia and health professionals need to be aware of the relevant laws and their requirements in their jurisdiction.