Family violence

Antenatal care provides an opportunity to ask women about exposure to violence. 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.

29.1 Background

‘Family violence’ may involve partners, siblings, parents, children and people who are related in other ways. It includes violence in many family contexts, including violence by a same sex partner, violence by young people against parents or siblings, elder abuse, and violence by carers in a domestic setting against those for whom they are responsible (Royal Commission into Family Violence Victoria 2016). It is also referred to as domestic violence.

‘Intimate partner violence’ includes any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship, including physical aggression, psychological abuse, forced intercourse & other forms of sexual coercion, various controlling behaviours WHO 2013.

In the context of these Guidelines, family violence is used as the overarching term and intimate partner violence is referred to when this was specified in studies.

29.1.1 Violence against women in Australia

• Women in the general population: The Australian Bureau of Statistics (ABS) estimates that 17% of all women aged 18 and over have experienced intimate partner violence (from either a current or previous partner) since the age of 15 ABS 2013. Among women who were pregnant at some time during a relationship and experienced violence with their most recent violent partner or their current partner, 54% and 22% respectively reported that they were pregnant at the time of the violence and 25% and 13% reported that violence occurred for the first time during pregnancy ABS 2013.
• Aboriginal and Torres Strait Islander women: The full extent of violence against women in Aboriginal and Torres Strait Islander communities is difficult to determine due to under-reporting, lack of screening by service providers, incomplete identification of gender and Indigenous status in many datasets, and the lack of nationally comparable data on family violence available from police, courts, health or welfare sources (Olsen & Lovett 2016). Despite under-reporting, surveys show that Aboriginal and Torres Strait Islander women report higher levels of violence and suffer higher levels of injury and death as a result of family violence than non-Indigenous women (Olsen & Lovett 2016).

29.1.2 Risks associated with violence in pregnancy

Violence in pregnancy poses significant risks for women. The risk of being a victim of attempted/ completed murder is three-fold higher (aOR 3.08; 95%Cl 1.86 to 5.10) among women abused during pregnancy than among those who are not (McFarlane et al 2002).

Intimate partner violence is associated with adverse reproductive outcomes, including multiple unintended pregnancies and/or terminations and delayed pregnancy care WHO 2013. Women who experience intimate partner violence during pregnancy are 4 times more likely to report depressive symptoms and 10 times more likely to report anxiety symptoms during pregnancy (Brown et al 2008). These symptoms frequently persist in the postnatal period (Woolhouse et al 2012) and affect a woman’s ability to form secure infant attachment 1st 1001 Days APPG 2015.

Women who experience violence during pregnancy are at increased risk of miscarriage (Morland et al 2008), pre-term labour and birth (Shah et al 2010) and having low birthweight infants El Kady et al 2005, Yost et al 2005, Silverman et al 2006, Shah et al 2010. Women physically assaulted during pregnancy also have higher risks of placental abruption, caesarean section, haemorrhage and infection than women without a history of being assaulted (El Kady et al 2005). In addition, violence before pregnancy is a major independent risk factor for hypertension, oedema, vaginal bleeding, placental problems, severe nausea and vomiting, dehydration, diabetes, kidney infection and/or urinary tract infection, as well as premature rupture of membranes (Silverman et al 2006).

29.2 Assessing for family violence

Recent guidelines in New Zealand NZ MoH 2016 and the United States USPSTF 2013 recommend routine enquiry about intimate partner violence among women of childbearing age (the latter noting a need for further research). However, guidelines in Canada (Canadian Task Force on Preventive Health Care 2003) and the United Kingdom (Feder et al 2009) do not recommend routine screening for family violence.

Some Australian states and territories have policies in place to support routine (New South Wales, Northern Territory) or targeted (Victoria) screening for family violence. While most states/territories do not have a dedicated screening tool for family violence in pregnancy, these are in development (Queensland), a tool that is used in other settings is recommended for use (Western Australia) or there are other mechanisms that prompt questioning (eg hand-held pregnancy records in South Australia, public hospital computerised recording system in Tasmania) AIHW 2015.

While the screening approaches vary considerably between jurisdictions, there are some common questions in use across the tools. Questions used in at least four jurisdictions are in the following list.

Questions used in assessment of family violence

• Within the last year, have you (ever) been hit, slapped or hurt in other ways by your partner or ex-partner? OR (In the last year,) has (your partner or) someone in your family or household ever pushed, hit, kicked, punched or otherwise hurt you?
• Are you (ever) afraid of your partner or ex-partner (or someone in your family)?
• (In the last year) has (your partner or) someone in your family or household ever (often) put you down, humiliated you or tried to control what you can or cannot do?
• (In the last year), has your partner or ex-partner (ever hurt or) threatened to hurt you (in any way)?
• Would you like help with any of this now?
• Are you safe to go home when you leave here?

Source: AIHW 2015

A review of validated screening tools that have been tested within a health-care setting and used in a antenatal context (either in part or full) found that Hurt, Insult, Threaten, Scream (HITS) and Humiliation, Afraid, Rape, Kick (HARK) tools were both considered potentially useful to recommend for national use in the antenatal context AIHW 2015. Both have been recommended for routine screening of women of childbearing age by the United States Preventative Services Task Force and cover a number of domains of family violence. However, a systematic review of ten screening tools found that three (Women Abuse Screen Tool [WAST], Abuse Assessment Screen [AAS] and HARK) had strong psychometric properties but that further testing and validation are critically needed, particularly in relation to cultural and gender sensitivities (Arkins et al 2016).

29.2.1 Effectiveness of screening

A Cochrane review O’Doherty et al 2015 found that screening by health professionals increased identification of women experiencing intimate partner violence (OR 2.95, 95% CI 1.79 to 4.87, moderate quality evidence) but did not have a clear effect on increasing referrals (low quality evidence). Face-to-face screening was not clearly more effective in women disclosing than written/computer-based techniques (OR 1.12, 95% CI 0.53 to 2.36, moderatequality evidence). Another systematic review (Hussain et al 2015) also found that face-to-face screening was not clearly more effective than either computer-based screening or self-administered written screening (with some overlap in included studies).

29.2.2 Acceptability to women

Studies found that women were largely supportive of routine enquiry:

• being asked was considered acceptable Roelens et al 2008, Roelens 2010, Spangaro et al 2011b, Lutgendorf et al 2012, Baird et al 2013, Stockl et al 2013,Salmon et al 2015
• family violence was considered an important domain of enquiry Rietveld et al 2010, Ben Natan et al 2011, Salmon et al 2015
• women would be willing to disclose if asked (Decker et al 2013).

However, women may not always feel able to disclose immediately (Salmon et al 2015). Reasons for not disclosing include not considering the violence serious enough, fear of the offender finding out and not feeling comfortable with the health professional (Spangaro et al 2010). Beneficial encounters are characterised by familiarity with the health professional, acknowledgement of the violence, respect and relevant referrals (Liebschutz et al 2008) and direct asking and care (defined as showing interest and a non-judgemental attitude) (Spangaro et al 2016). Multiple assessments for family violence during pregnancy increase reporting O’Reilly et al 2010.

As women should be assessed for family violence without the partner present, strategies need to be developed so that a woman’s partner can be involved in other domains of enquiry when assessment for psychosocial risk factors that affect mental health is conducted (Rollans et al 2016).

29.2.3 Acceptability to health professionals

While many health professionals think screening is important (DeBoer et al 2013), some are reluctant to enquire about family violence Roelens 2010, Ben Natan et al 2011, Shamu et al 2013. Factors increasing a health professional’s likelihood of screening women included having previously screened women (Ben Natan et al 2011), having a therapeutic relationship with the woman (LoGiudice 2015), knowledge of prior abuse (Lutgendorf et al 2010), recognising silent cues (LoGiudice 2015), having scripted questions (Spangaro et al 2011a), interdisciplinary collaboration Chang et al 2009, Kulkarni et al 2011, Mauri et al 2015 and access to resources (Chang et al 2009) and referral services (Spangaro et al 2011a).

29.2.4 Barriers to screening

The most commonly recognised barrier to screening was lack of training Garcia & Fisher 2008, Chang et al 2009, Lazenbatt et al 2009, Lutgendorf et al 2010, Roelens 2010, Kulkarni et al 2011, Spangaro et al 2011a, DeBoer et al 2013, Shamu et al 2013, Salcedo-Barrientos et al 2014, Baird et al 2015, Infanti et al 2015, Mauri et al 2015. Other barriers identified included:

• variations in timing and the manner in which screening takes place (LoGiudice 2015)
• lack of peer support (Garcia & Fisher 2008), confidence (Lazenbatt et al 2009) or continuity of care (Lauti & Miller 2008)
• presence of the woman’s partner (LoGiudice 2015)
• women’s unwillingness to disclose (Mauri et al 2015)
• time constraints Chang et al 2009, Lutgendorf et al 2010, Roelens 2010
• cultural taboos (Mauri et al 2015)
• health professionals’, attitudes to violence Ben Natan et al 2011, Salcedo-Barrientos et al 2014
• concerns about privacy and confidentiality (Lauti & Miller 2008)
• uncertainty regarding management and referral options Lutgendorf et al 2010, LoGiudice 2015
• need for debriefing (Lauti & Miller 2008), guidelines and employer support (Finnbogadottir & Dykes 2012).

The WHO recommends that all health professionals be trained in first-line response to family violence. The steps are to: listen, believe, inquire about needs, validate the person’s experience, enhance safety and offer ongoing support.

Health service support for health professionals includes provision of regular training, support and debriefing, provision of private screening spaces, documentation, policies and protocols, quality assurance and funding.

29.2.5 Interventions

There is insufficient evidence to assess the effectiveness of interventions for family violence on pregnancy outcomes (Jahanfar et al 2014). However, brief advocacy interventions (providing information and support to access community resources, including legal, police, housing and financial services) may provide small short-term mental health benefits and reduce physical abuse (Rivas et al 2015). Home visits from nurses or community health workers may also reduce episodes of physical abuse Prosman et al 2015, Sharps et al 2016. In the context of antenatal care in Australia, safety assessment (see Section 29.4), referral to relevant support services (eg women’s resource centres or refuges) is an appropriate response to disclosure of family violence.

29.3 Discussing and responding to family violence 

Discussion of family 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 with the same person. It is important for health professionals to enquire about family violence in private and in a sensitive manner and provide a response that takes into consideration the complexity of women’s needs.

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

Key considerations in discussing and responding to family violence

• Enquire about family violence when alone with the woman
• Explain that the woman’s responses will be kept confidential (subject to legal requirements)
• 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 family violence
• Affirm that the woman has made an important step by discussing her experiences
• Reinforce that family violence is against the law
• Reinforce that the woman should not self-blame
• Affirm that the decision to discuss family 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 safe house, family or friends, hospital, women’s refuge)
• Encourage the woman to access specialist support services (eg woman’s health centre, social worker, counsellor, mental health service, family violence and sexual assault service)
• Inform the woman of her legal right to protection and provide information on legal support services
• Inform the woman that disclosure of family violence may require further discussion and possible reporting in relation to child protection issues ^[22]
• Be aware of security supports that can be used to protect the woman and yourself if needed
• Document a woman’s responses (ensuring that records are kept confidential and secure)
• Report any incidents of violence according to organisational policy and jurisdictional legislation

Sources: Adapted from (Eastern Perth Public and Community Health Unit 2001) and NHMRC 2002.

Health professionals with limited experience in responding to family violence can enhance their practice by:

• seeking training and support (eg clinical supervision) where available (see Section 29.4)
• planning a response to disclosure of violence, including considerations of safety, confidentiality, sensitivity and informed support
• being familiar with specialised counselling services, emergency housing agencies and legal support services in the local area.

29.3.1 Considerations in Aboriginal and Torres Strait Islander communities

In Indigenous communities, violence against women is conceptualised within extended families and the wider community (Olsen & Lovett 2016). Family violence is understood to be the result of, and perpetuated by, a range of community and family factors, rather than one individual’s problematic behaviour within an intimate partnership.

No one causal factor can explain violence against Aboriginal and Torres Strait Islander women (Olsen & Lovett 2016). Instead, a number of interrelated factors have been identified, highlighting the complex and cumulative nature of violence and victimisation including colonisation and the breakdown of culture, intergenerational patterns of violence, alcohol and other drugs, and socioeconomic stressors (Olsen & Lovett 2016). These factors also influence responses to disclosure of family violence by Aboriginal and Torres Strait Islander women. Confidentiality and privacy are important considerations. Women should be asked about who they would like to be involved in their care and offered a clear choice about referral options, including both Aboriginal-specific services and mainstream services.

It is important to respect and understand that, despite the disproportionate burden of violence against Aboriginal and Torres Strait Islander women, violence is not normal or customary in these communities (Olsen & Lovett 2016). Indigenous Australians are diverse peoples who, while having a number of areas of commonality, differ in their languages, culture and history. Not all Aboriginal and Torres Strait Islander women are subjected to violence and not all communities have high rates of violence.

Approaches to addressing factors underlying family violence in Aboriginal and Torres Strait Islander communities are beyond the scope of these Guidelines. Some relevant resources are identified in Section 29.4.

29.3.2 Considerations among migrant and refugee women

Women from migrant and refugee backgrounds who are experiencing violence may be disadvantaged by a lack of knowledge about their rights, lack of good support systems, and social isolation (Taft 2013). They may be experiencing abuse by multiple people, including in-laws and intimate partners.

Small studies have noted the need to focus on the individual woman beyond ethnicity and cultural differences (Byrskog et al 2015) and to consider different definitions of violence (Byrskog et al 2015), cultural factors influencing disclosure (Wellock 2010) and the need for involvement of independent interpreters (Wellock 2010) or bicultural health workers.

Cultural taboos may surround the issue of violence in families and this may make it difficult for women to disclose without additional encouragement, support and sensitivity (Taft 2013). The building of a trusting therapeutic relationship is essential to facilitate this disclosure. Cultural sensitivity but, equally importantly, non-judgemental and supportive practice will make it ‘culturally safe’ for women to find the appropriate moment to speak about their concerns with a health professional.

29.3.3 Considerations in rural and remote areas

Assisting women experiencing family 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
• difficulties when the health professional has a relationship with the woman (eg through family, kinship or friendship), particularly if mandatory reporting is required.

29.3.4 Practice summary: assessing for family violence

When

As early as practical and at subsequent antenatal visits.

Who

• Midwife
• GP
• obstetrician
• Aboriginal and Torres Strait Islander health worker
• multicultural health worker.

What

• Discuss assessment for family violence
  Explain that enquiry about family 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 family violence in privacy (eg without her partner present).
• Take a holistic approach
  If a woman affirms that she is experiencing family 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 family 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 family violence with women and assisting them if they are experiencing family 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.

29.4 Resources

29.4.1 Training

• DV-Alert Lifeline offers nationally recognised training and non-accredited training across all states and territories in Australia. DV-alert is funded by the Department of Social Services and is free for front-line community and health workers.

29.4.2 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.
• Futures without Violence: online tools.
• 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.
• RACGP (2014) Abuse and Violence. Working with our Patients in General Practice.
• Strengthening Hospital Responses to Family Violence
• WHO (2014) Health care for women subjected to intimate partner violence or sexual violence. A Clinical Handbook.

29.4.3 Safety assessment

• Danger Assessment helps to determine the level of danger to a woman experiencing abuse.

29.4.4 Indigenous communities

• Olsen A & Lovett R (2016) Existing knowledge, practice and responses to violence against women in Australian Indigenous communities: Key findings and future directions. Sydney: Australia’s National Research Organisation for Women’s Safety.