Discussion paper, January 28, 2000
Dr.
Barbara Lent, Dr.
Patricia Morris, Dr. Shelley
Rechner
Introduction
Because the issue of violence against women is such an important social problem
with serious health consequences for abused women and their children, health
professionals providing care to pregnant women need to consider how the experience
of abuse in current or past intimate relationships could affect their patients
during pregnancy, labour, and delivery. This paper reviews current evidence
from the medical, nursing, and midwifery literature, with a particular focus
on clinical issues, and identifies some important, but as yet unresolved issues.
For a more comprehensive analysis of these issues, readers are referred to other
materials, some of which are listed in the bibliography.
For the purposes of this paper, we use the terms violence and abuse interchangeably,
to mean the use of physical force and verbal threats to intimidate another person
with whom one has an intimate or other close family relationship. The abuse
can manifest as physical, psychological, or sexual abuse.
Why violence against women is an important health issue
In a 1993 Statistics Canada1 survey of 12 300 adult women, 29% of
the women who had ever been married or involved in common-law relationships
reported that they had been assaulted by their partners and 51% reported at
least one incident of physical or sexual violence since the age of 16. Younger
women (18 to 24 years), women whose household incomes were less than $15 000,
and women whose marriages (or common-law partnerships) had lasted less than
2 years reported higher rates of abuse; neither educational level nor geographic
location was associated with variation in the rate of abuse. When asked about
the occurrence of violence in association with their pregnancies, 21% of women
abused by a partner reported being assaulted during pregnancy.
The incidence of physical abuse in pregnancy has been examined in two Canadian
studies. When women receiving prenatal care from family physicians and obstetricians
working in either private, community-based, or university teaching clinics in
Toronto were asked about their experience of physical abuse in pregnancy, 6.6%
reported physical abuse during the current pregnancy and 11% reported being
abused prior to the current pregnancy.2 Similarly, a recent study
of pregnant women attending a publicly funded, community-based health program
in Saskatoon found that 5.7% reported physical abuse during pregnancy and 8.5%
reported experiencing abuse in the year prior to their third-trimester interview.3
The risk of abuse for this group of women was greater if they were aboriginal,
if their partners had a problem with alcohol, and if they had high levels of
perceived stress in the preceding year.
Numerous studies4,5 have shown that abuse accounts for a substantial
proportion of the injuries that bring women to hospital emergency departments.
Abused women are more likely to present with physical symptoms, such as headache,
irritable bowel syndrome, and chronic pelvic pain, than nonabused women.6-8
The prevalence of psychological problems, such as depression, suicidal behaviour,
and substance abuse, is higher in abused women as well.9,10
Looking at 1992 Canadian homicide statistics11 spousal homicides
accounted for 17% of solved murders, with men killing their wives in 84% of
these cases and women killing their husbands in 16% of cases; 42% of family-related
homicides involved a history of domestic violence reported to police. During
the period from 1974 to 1987, 31% of men who killed their wives went on to commit
suicide immediately following the incident.12
Although a systematic review of the literature13 found no consistent
relationship between violence during pregnancy and adverse pregnancy outcomes,
some of the studies reviewed did find a difference between abused and nonabused
women’s outcomes of pregnancy in mean birth weight and incidence of low
birth weight.14,15 Both direct and indirect causal pathways have
been postulated to explain such adverse outcomes13,16
Blunt trauma to a maternal abdomen has been shown to lead to placental abruption,
preterm labour and delivery, fetomaternal hemorrhage, and fetal death.17
Assaults resulted in more pregnancy complications than motor vehicle accidents
or falls, the two other major causes of trauma during pregnancy. 17
Physical, sexual, or emotional abuse during pregnancy can lead indirectly to
adverse pregnancy outcomes by affecting pregnant women’s health behaviours.13,16
For example, abuse during pregnancy has been associated with delayed entry into
prenatal care, increased behavioural risks such as the use of tobacco, alcohol,
and illicit drugs, and poor maternal nutrition, all of which have been associated
with increased risk of low birth weight and preterm delivery.10,18,19
Labour and delivery can be particularly difficult for women with a history
of sexual abuse, and physicians and other birth attendants unaware of the abuse
could have difficulty understanding their seemingly unusual behaviour. As labour
progresses, the increasing pain, the subsequent sense of loss of control, and
the repeated pelvic and genital examinations by multiple caregivers can result
in unexpectedly extreme responses from labouring women¾ from too quiet and passive
to screaming, crying, or uncontrollable terror. Other women respond by becoming
overly controlling or demanding. Still others dissociate during labour or delivery.
Some accoucheurs have even speculated that a history of abuse plays a role in
inadequate fetal descent and prolonged second stage, based on their interactions
with abused women during labour.20
Role of the caregiver
How to identify women with a history of abuse
Screening.
Because of the high prevalence of abuse in the general population, all pregnant
women should be screened for past or current history of abuse. Rates of disclosure
might be improved if women are asked about abuse at the same time that they
are asked about other social risk factors. Some clinicians prefer to ask about
abuse during history-taking, while others prefer to use standardized tools.
The Woman Abuse Screening Tool is reliable and valid and has been shown to be
effective in identifying abuse in adult women patients attending their regular
family physicians for prenatal care or periodic health examinations or for assessment
of particular health problems.21 It has been included in the Antenatal
Psychosocial Health Assessment (ALPHA) form,22 an evidence-based
screening tool that can be used as a checklist for psychosocial enquiry and
will soon be incorporated into the Ontario Antenatal Record. Women should never
be asked questions about abuse in the presence of their partners.
Red flags.
Caregivers might be particularly alerted to the possibility of abuse in the
following clinical situations.
Unwanted pregnancy
Teenage pregnancy
Delay in seeking prenatal care23
Inadequate attendance at prenatal education
Recurring or unexplained psychosomatic illness
Addiction to alcohol, tobacco, or psychotropic drugs, or use of illicit drugs24
Unexplained injuries, particularly to the breasts and abdomen
History of psychiatric illness
Barriers to identification and disclosure. Women might be reluctant to disclose
a history of abuse for a variety of personal and social reasons (eg, shame,
embarrassment, uncertainty about housing or financial options, etc) or because
previous attempts at disclosure were met with disbelief or denial by other professionals
or by family members or friends. Health care providers might be reluctant to
ask about abuse because of a lack of understanding of the importance of abuse
as a health issue or a lack of information about community resources. Caregivers’
own experiences as victims, perpetrators, or child witnesses to abuse could
also affect their readiness to ask about abuse.
What to do on disclosure
When patients disclose a history of abuse, it is crucial that health care providers
respond in a way that makes these patients feel believed and supported. It is
not appropriate to question behaviour during the abusive episodes or to minimize
the seriousness of the abuse. Patients should be provided with information about
how to get help in dealing with their experiences.
Trauma management
In situations where pregnant women have sustained direct trauma to the abdomen,
continuous fetal heart rate monitoring and external tocodynamometry are recommended.
Controversy exists over the duration of monitoring; recommended times range,
from 30 minutes17 to 48 hours.25 Women who are Rh negative
require Rh globulin.17,26-27
Referral and collaboration with other physicians, allied health professionals,
and community agencies
Some abused women will need help in making changes in their lives as they sort
out their experiences of abuse. In addition to providing clinical care, which
might include helping them with their physical and psychological symptoms and
providing support, health care providers might decide to refer such patients
to other health care professionals or to community agencies for assistance in
obtaining shelter, sorting out financial options, exploring legal options, and
arranging further psychological counseling for themselves and their children.
Safety issues
When abuse is disclosed, the importance of having a safety plan should be stressed
by health care providers or other helpers from the community. Many community
agencies can provide written materials to help women develop safety plans. If
there are children in the family, health care providers should enquire about
whether they have ever been abused or if there is risk of abuse and determine
whether the physical and emotional environment is safe for the children. Any
concerns about the safety of the children must be reported to the appropriate
child protection agencies.
Caring for other family members
Family physicians typically provide medical care to members of pregnant women’s
families as well and might find themselves caring for partners or other family
members who perpetrated the violence. In such situations, physicians must ensure
that the needs of the abused women and the perpetrators are addressed independently,
such that their rights to autonomy, confidentiality, honesty, and quality of
care are maintained.28 Couple or marital therapy is contraindicated
unless the woman’s safety can be ensured and the man has taken responsibility
for his abusive behaviour.
If current abuse is disclosed, accoucheurs will need to determine whether the
home environment is safe for a newborn (and for other children) and whether
the woman and her partner are physically and emotionally able to care for a
newborn appropriately.
Confidentiality and reporting issues
Women will feel more comfortable disclosing if they know that the details of
their disclosure will be kept confidential by caregivers. This is particularly
important for family physicians who also provide care to other family members.
Practitioners who are concerned that a history of abuse might affect their patients’
tolerance of certain procedures (eg, transvaginal ultrasound) should check with
their patients about what information can be disclosed to these other caregivers
(eg, obstetrical consultants, delivery room nurses).
Practitioners are not obliged to report past or current episodes of abuse,
no matter how violent. Practitioners should, however, be aware of the recommendations
of their provincial colleges with respect to the duty to warn in situations
where they become aware of a serious risk of violence to a third person.29
If the possibility of child abuse arises, practitioners must inform local child
protection agencies of their suspicions.
Documentation
As in any clinical situation, disclosures of abuse and relevant positive and
negative findings on physical examination should be well documented.30
Good records of repeated injuries or recurrent vague complaints might help physicians
consider the possibility of abuse, even when women are reluctant to disclose.
Moreover, thorough documentation might obviate the need for a court appearance
should the case come to trial.
Exactly what information should be recorded on the standardized antenatal record
forms that are sent to the delivery room remains unclear. A history of violence
before or during pregnancy can affect labour and delivery, but women might not
want staff in the delivery room to know about their experience because they
do not have long-term, trusting relationships with those caregivers. It is important
that caregivers check with their patients about what information to share with
other caregivers.
Future directions
Clinical research
Prevalence. Because the frequency of an event is an important consideration
in deciding whether to screen, it would be helpful for practitioners to have
accurate, current estimates of the prevalence of violence in Canada, with attention
to specific populations. We need to determine regional, social, and cultural
differences that would assist policy planners and clinicians to provide better
service to abused women and their families.
Clinical clues and risk factors for violence.
Practitioners would be helped by more research into the clinical clues that
suggest violence is an issue in their patients’ lives, including important
risk factors.
Given the increasing numbers of refugee and immigrant women coming to Canada,
practitioners require more information about their needs. We need to know how
to ask about abuse in a culturally sensitive fashion and how best to serve women
with violence issues complicated by language barriers, immigration status problems,
poverty, and isolation. Little attention has yet been addressed to meeting the
needs of these particular women.
Clinical outcomes.
More research is needed on the effect of violence on pregnancy outcomes. Attention
is required to the particular physiologic mechanisms through which violence
could affect pregnancy outcomes. In addition, little is known about the effect
of aspects of our clinical care; for example, do violence-screening strategies
help or hinder our patients? In a recent editorial, MacMillan emphasized the
need to expand the extensive work on low birth weight to include an examination
of its association with abuse during pregnancy.31 In addition, she
stresses the need for a population-based study to determine the long-term clinical
outcomes for women and their children.
Roles of caregivers.
Research needs to be done on the roles of various caregivers in identifying
and managing domestic violence. Health care is changing rapidly: we are experiencing
new kinds of caregivers (nurse-practitioners, midwives), changing types of practice,
and increasing mobility of health care providers. With these changes come the
challenges of communicating sensitive patient information, such as a history
of violence and abuse, to colleagues and sharing care of patients in collaborative
ways that best help women and their families.
Quality of care.
Now that practitioners are becoming more aware of the importance and frequency
of violence issues in the lives of pregnant patients, we need to examine how
well we are helping these patients. We need to look at how extensively and how
sensitively we screen. Are non-abused women intimidated or put off by our style
of questioning? Do some screening efforts harm abused women, and if so, which
ones?
Questions have been raised about the role of a practitioner's own gender in
his or her ability to help abused women. If there are differences related to
a physician's sex, what can practitioners do to minimize barriers to disclosure
or assistance? Another strongly held belief is that the duration of the doctor-patient
relationship substantially affects disclosure or subsequent management of the
problem. If a long-term relationship facilitates disclosure or helps the patient
in any way, how can new caregivers short cut the development of a trusting or
helpful relationship? Can other professionals or agencies use a family physician’s
previously established relationship to enhance their work with that family physician’s
patients? On the other hand, does a long-term relationship actually hinder screening,
identification, and disclosure? Are practitioners and agencies new to patients
better able to help with violence issues?
Further investigation is also needed into patients with multiple problems,
eg, patients with a history of abuse who abuse substances. Are we giving these
women the comprehensive care they need? Can one practitioner respond to all
their needs, and how do we share this type of care with colleagues whose expertise
complements our own?
More work needs to be done to determine whether certain interventions are better
suited to specific patient populations (adolescents, new Canadians), and whether
certain practitioners are better suited to specific roles (family physicians,
delivery room nurses, community workers).
Health services research
Financing health care in Canada is undergoing great change. It is unclear how
the current fiscal crisis affects practitioners’ abilities and willingness
to help abused women. Do time or funding constraints affect our identification,
management, and referral of these women, and if so, how? If we take time to
screen our pregnant patients for a history of violence, we need to be sure that
referring agencies have the capacity to respond to the increased numbers of
women seeking their help.
Research is needed into access to health care for women affected by violence.
For example, do pregnant or postpartum women recently arrived in shelters have
adequate access to medical, nursing, midwifery, or lactation consultant care?
We need to know whether practitioners are defining their communities to the
best advantage of women affected by violence? Which patients experience access
problems due to geographical location, socioeconomic status, ethnicity, or other
factors?
A great deal of community service and advocacy work is done after hours by
health care practitioners, but this work is often poorly rewarded in any official
way. Research into roles and service would enhance this recognition process.
It could also invite new members and create new partnerships between community
agencies and professionals or among different groups of professionals. Such
research would promote public awareness of the extent of violence in our society
and the roles and involvement of health care professionals in dealing with this
issue.
Finally, although we recognize that health care practitioners are exposed to
violence in both their personal and professional lives, little work has been
done to explore the extent to which they are affected by these experiences.
We need to learn more about self care, coping strategies, peer support, and
supervision of patients with difficult problems.
Education
Professional education.
Learners need to become familiar with the manifold presentations of violence
and to become comfortable talking with patients about abuse. They need to be
ready to refer to appropriate helping agencies. They need to see their preceptors
and senior clinicians role model these clinical skills.
Education on violence for health care practitioners needs to be evidence based
and properly evaluated. Effective methods for disseminating new findings to
clinicians need to be implemented. We need to consider whether this education
should be multidisciplinary or with groups of peers, and whether survivors of
violence have a role in the education of professionals.
Special obstetrical education programs, such as the Advanced Life Support in
Obstetrics (ALSO) and Advances in Labour and Risk Management (ALARM) courses,
need to incorporate violence issues directly into the curriculum. Domestic violence
should not be marginalized by including it as a subsection of abdominal trauma.
Although all practitioners should be aware of violence issues and be able to
assist patients appropriately, some caregivers might be interested in developing
advanced skills in this area. Consideration should be given to creating educational
opportunities for providing advanced training in psychosocial care of obstetrical
patients.
Public education.
Strategies need to be developed, in conjunction with community agencies, to
assist people affected by abuse and violence to use available community resources.
Educational efforts must inform patients that violence in pregnancy is an important
health issue and worthy of our attention. A variety of media, including pamphlets
and posters in medical offices and hospital delivery rooms, should be used to
inform the public of health care practitioners’ awareness of violence as
a health care issue and to encourage the public to discuss these issues with
their family physicians and other health care professionals.
Evaluation of educational endeavours.
Public and professional educational endeavours need to be evaluated. We need
to know which strategies have helped women and which have been ineffective or
harmful. Involvement of survivors of violence, shelter workers, and other allied
health professionals would greatly enhance such research.
Conclusion
Not only can the experience of violence and abuse in past or current intimate
relationships affect the physical health and psychological well-being of women
and their children, these negative experiences can also play a role in pregnancy
outcomes and in labour and delivery. As health care professionals, we need to
be aware of these issues and maintain a high index of suspicion for the possibility
of abuse in our clinical work. Because of their long-term relationships with
patients and because they focus on both physical and mental health issues with
their patients, family physicians are in a unique position to identify patients
with a history of abuse.
As attention to these issues is relatively new, many questions remain unresolved.
Collaborative projects with family physicians, obstetricians, midwives, patients,
and others who work with abused women will help us all to better understand
these women's experiences and to provide exemplary care.
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