Antenatal Routine Enquiry Domestic Abuse

1. Antenatal Routine Enquiry Domestic Abuse A Training Programme Developed by the “All Wales Midwives and Health Visitors Networking Group” Funded by the Welsh Assembly Government Antenatal Routine Enquiry for Domestic Abuse - An All Wales Care Pathway

2. Programme Objectives • To increase practitioners’ knowledge of domestic abuse and its relation to pregnancy • Increase professional confidence in dealing with domestic abuse and routine enquiry • Using the Care Pathway Documentation, improve identification and support for pregnant women living with domestic abuse • To provide information of resources available to staff dealing with domestic abuse issues or who may be experiencing domestic abuse themselves.

3. Group Rules • Confidentiality - anything said stays within the group • Maintain a non judgmental attitude • Use each other for support if difficult issues arise • Respect the views and opinions of other participants • Try not to jump to conclusions or make assumptions

4. Domestic Abuse • The Welsh National Strategy Definition:- • “The use of physical and/or emotional abuse, or violence, including undermining of self confidence, sexual violence or the threat of violence by a person who is or has been in a close relationship” • Welsh Assembly Government (2005 p6)

5. UK Statistics Two women are killed each week as a result of domestic abuse - 50% of murdered women are a result of domestic violence(Home Office 1999) • Financial Costs to Services:- • The cost to public services is £3.1 billion each year • Total cost of domestic violence for the state, employers and victims is estimated at £23 billion • The cost of physical injuries to the NHS = £1.2 billion for GPs and hospitals - additional cost of £176 million for mental health resources(Women’s Equality Unit 2004)

6. UK Statistics • Domestic Abuse accounts for 1/4 of all violent crime in the UK • One incident of domestic abuse is reported to the police every minute in England and Wales • Domestic abuse is hidden - therefore under reported and recorded (Welsh Assembly Government 2005) • 1 in 10 women are severely beaten by a partner at some point during their lifetime • 25% of attacks occur when a woman is pregnant • 41% of female homicide victims are killed by a partner or former partner (Welsh Women’s Aid 1999)

7. Types of Abuse • PHYSICAL - Pushing, shoving, hitting, beating, physical abuse with a weapon, torture, mutilation, murder • SEXUAL - Unwanted sex, unwanted sexual touching, rape, incest, pornography, forced prostitution • FINANCIAL - Control of finances, preventing a partner from having a job and other activities, education which would promote independence • SPIRITUAL - Ridicule or punishment to destroy religious beliefs. Not allowing her to practice her own religion. Forcing a woman to adhere to a religious practice that is not her own • EMOTIONAL - Yelling insults, threats, abusive language, isolation, constant put downs ‘mocking’

8. Domestic Abuse can be carried out by ……… • Partner/Ex-partner • Husband/Wife • Boyfriend/Girlfriend • Family Member

9. Abuse & Gender • The majority of abuse is perpetrated by men against women and children (Welsh Women’s Aid 1999) • Where partners abuse each other, 38% of women feared for their lives compared to only 7% of men (Johnson & Hotton 2001) • Consider same sex relationships • Family abuse could be son to mother • Cultural differences

10. The Cycle of Violence • Violence • Violence • Remorse • Signals • Hearts and Flowers • Carping Same Old Stuff (SOS)

11. Why Women Don’t Leave • Love for the partner • Financial Implications • Reprisals from ‘his’ or her family • Concerned that her children may be taken from her • Being stereotyped/stigma • Lack of support from family or friends/social isolation • Feeling a failure • Unaware of how to get help • Prejudice, stereotyping and discrimination from others • Leaving is ‘risky’

12. ‘Why Mothers Die’ 2000-2002 • 12 women died - all had a known history • 14% (55 of 391) of all women whose deaths were reported had self reported history of violence to a health care professional (this figure is an underestimate) • Little or no help was offered to the woman • 62% of women under 18 years had suffered violence in the home • 71% booked late or were poor/non attendees at Antenatal Clinics • NONE had been routinely asked about domestic abuse in pregnancy • Family interpreters used inappropriately - evidence of family “secret keeping”

13. Suggested Indicators of Abuse (RCOG 2004) • Late booking/poor or non attendance at clinic appointments • Poor obstetric history • Unexplained/repeated hospital admissions or repeated attendance at Accident and Emergency Departments • Non compliance with treatment regimes/early or self discharge from hospitals • Recurrent sexually transmitted diseases • Repeat presentation with depression, anxiety or self harm/ psychosomatic symptoms • Minimisation of signs of violence on the body • Constant presence of the partner at examinations - he may answer questions for her and be unwilling to leave the room • A women who is evasive or reluctant to speak in front of or disagree with her partner

14. Effects of Domestic Abuse on a Woman’s Health • Bruises, cuts, burns, scratches, broken bones • Injuries that are untended and of several different ages, especially to the head, neck, breasts, abdomen and genitals • Rape and sexual assault • Gynaecological injuries • Unplanned or unwanted pregnancy • Mental illness - depression, panic attacks, anxiety, suicide • Isolation • Enforced poverty • Coping mechanisms such as smoking, alcohol and drug abuse, misuse of prescribed drugs

15. Consequences to the mother and the unborn Pregnancy specific injuries - breasts, abdomen, genitalia, ruptured uterus, liver or spleen, antepartum haemorrhage, premature rupture of membranes Jealousy and anger toward unborn baby resulting in - Repeated miscarriages, placental abruption, premature labour, intra uterine growth retardation, low birth weight, fetal injury/fractures, stillbirth

16. Consequences in the Post Natal Period • Psychological problems - fear of not being a good mother, having the baby taken away by social worker • Abuse may become worse • Level of danger increases if she decides to leave the relationship • Increased financial control • May lead to social isolation • Doesn’t allow professionals to visit alone • If abuse continues, baby will also be at risk of abuse

17. What Women Want ‘I wish I’d been asked about what happened. I was so ashamed, but I really wanted to tell them. They didn’t ask me though and I didn’t have the courage to tell them myself. Even though he wasn’t there I lied for him just like I always did. They just gave me some painkillers and sent me home’. (Langley as cited in Bewley, Friend & Mezen (1997))

18. Policy & Position Statements Every midwife should assume a role in the detection and management of domestic abuse (RCM Position Statement 19a, 1999) Enquiry about a history of violence should be included when taking a social history at booking or at another opportune point in the antenatal period (RCOG 2004)

19. How can Midwives & Health Visitors help reduce the risks? • Ask all pregnant women about domestic abuse • Make sure she’s alone when asking about abuse • Provide access to support services who may be able to help (All Wales Information Card) • Assess the woman’s level of risk/safety needs e.g. ‘MARAC’ • The Care Pathway for all women in Wales

20. Care Pathway Approach • Women Centred / Clinically Driven • Evidence Based • Document by Exception • Underpinned by National Service Frameworks • Provides structured framework for practice and development • Multi Disciplinary Document • A Useful Tool for Audit and Evaluation • Electronic Patient Records

21. Care Pathways - 10 Standards Confidentiality Routine Enquiry Disclosure Record Keeping Risk Assessment Child Protection Safety Planning for Staff and Victim Provision of Information and Referral Support & Supervision of Staff Education and Training

22. Confidentiality Standard 1 - Professional Concerns • I cannot keep this information to myself • If I tell other agencies she may never trust me again • She may fear the child(ren) being taken away • The perpetrator may find out

23. Confidentiality • Begin by giving All Wales Information Card • Tell the woman that you respect her need for confidentiality. However, anything she tells you may be shared with other agencies if you feel that either she or the baby/child(ren) are at risk • Ask for her consent to share information • Where there are child protection concerns, consent is not essential • If you are concerned about the welfare of a child - seek appropriate guidance and support

24. Routine Enquiry - Why Professionals may not ask • Don’t know how to deal with/no time to deal with positive answer • Don’t know how to ask • “I’m experiencing abuse myself” • Don’t want to offend the woman • I don’t know what services are out there • Her partner is always with her • I’m worried that I won’t be supported by management

25. Routine Enquiry - If we don’t ask • Women will continue to be abused • We will be failing in our responsibilities • We will be colluding with the perpetrator

26. Routine Enquiry - How do I ask? • Assess the environment - the partner may be ‘hiding’ • Never attempt Routine Enquiry if the partner is present • Only ask if the women is alone

27. If you are unable to see a women alone ………. “Flag” as a priority - consider Routine Enquiry next visit or when it is safe to do so

28. Routine Enquiry - Standard 2 • Ensure lone contact with the woman at least once during her pregnancy • Begin by giving All Wales Information Card • Say something like:- • “Domestic abuse affects many women during their lifetime and often starts or becomes worse in pregnancy. This is why we are asking all women about domestic abuse routinely throughout their pregnancy.” • Then commence All Wales Pathway “DA1”

29. Disclosures - Standard 3 • Complete Pathway “DA2” in order to highlight severity of risk • Validate that abuse is wrong and it is not her fault • Access appropriately trained interpreters (if needed) - never rely on family members • Ask for consent for referral to other agencies • Respect confidentiality but adhere to All Wales Child Protection Guidelines

30. Documentation - Standard 4 • Each Trust/LHB will ensure that staff are clear about the documentation process • Record events using the woman’s own words - do not‘lead’ her • Use ‘Free Text Space’ on the pathway for documentation • Document whether children were present at time of abuse • Liaise with A&E staff/police if necessary

31. NEVER DOCUMENT ANY INFORMATION IN THE HAND HELD RECORDS - THIS COULD BE DETRIMENTAL TO A WOMAN’S SAFETY

32. Hand Held Notes - “How do we know if the question’s been asked?” • If nothing is written then the question has not been asked • If the question has been asked but no disclosures made, note “Routine Enquiry 1” • If the question has been asked and disclosures made, note “Routine Enquiry 2” • This will alert other professional to look elsewhere

33. Risk Assessment - Standard 5 • Assess level of risk by completing DA2 • Carry out a risk assessment of the environment • Seek support/guidance from local Domestic Abuse Unit/ Domestic Abuse Co-ordinators • NB Consider the pathway as a whole • Take into account any ‘strange’ behaviour • If a woman perceives herself to be in great danger then refer to the MARAC Process or its equivalent

34. Children Protection - Standard 6 Establish whether children are present within the home when abuse is taking place 90% of children in violent homes are in the same room or next room when violence occurs (Hughes 1992) Assess level of danger (use DA2 Pathway) Consider other situations which may impact on the health of a child and take appropriate action Named Nurse/Midwife for Child Protection must be informed of any concerns for the welfare of a child Involve multi agency partnerships Ask the woman for consent to share information NB Consent is not essential where there are imminent child protection concerns/threats to their safety

35. Child Protection - How does it affect children? Physical Babies lying in cribs, being scattered with broken glass as windows are smashedBabies and children being physically caught in the crossfire whilst being held in their mothers armsHitting bottles out of baby’s mouthChildren displaying anger and aggression to mother/others; obvious injuries such as broken bones, bruises (Hester, Pearson & Harwin 2000) EmotionalFear, insecurity, feeling guilty or to blame, bedwetting, nightmares, withdrawal, difficulties at school, truanting (Hester, Pearson & Harwin 2000) NeglectA woman who is barely surviving may not see her child’s health needs as a priority e.g. not attending GP appointmentsSocial isolation (Hester, Pearson & Harwin 2000)

36. Safety Planning - Standard 7 • If you don’t feel comfortable DON’T ASK • Build a trusting non judgemental relationship • Encourage the woman to assess her own safety needs • Remember that leaving is a PROCESS • Review current risk - her own life and the children. Leaving a relationship is the most risky time for a woman • Offer appropriate accurate information • Be an advocate for the woman with other agencies (with consent)

37. Provision of Information and Referral - Standard 8 • Adopt a calm, open approach • Give All Wales Information Card • Give information that is non judgemental and accurate • Display information within your own Trust/LHB • Ensure all local support agency telephone numbers are current. If not this could endanger the woman

38. Support & Supervision of Staff - Standard 9 • Discuss with line manager/named midwife or nurse for child protection • Access clinical/midwifery supervision in order to debrief • Remember that you are not alone when working with women. Adopt a multi agency approach. Domestic abuse is everyone’s responsibility • Explore own issues which may influence practice and seekadvice accordingly • Adhere to Minimum Standards and principles of the Pathway • Develop skills and identify own training needs • Consider advice and support from local domestic abuse units

39. Education & Training - Standard 10 • Awareness of physical and general indicators • Midwives and health visitors to use Routine Enquiry as part of antenatal care • All Trusts/LHBs to adopt the All Wales Pathway for Domestic Abuse as Good Practice (Welsh Risk Pool Standard) • Domestic Abuse to be placed on Trust and LHB Agenda • Campaign for Trust/LHB Policies for staff experiencing Domestic Abuse

40. Workshop Scenarios

41. Jake • Jake is 3 years old. He has just started nursery • His mum and dad are married - dad works long hours in a factory • He won’t allow Jake’s mum to work • Jake’s dad controls all the family’s money and doesn’t let Jake’s mum have her own money except to buy household essentials. She doesn’t drive and has no family support nearby • Jake’s dad frequently loses his temper and hits his mum using belts, chairs or anything else he can get hold of as a weapon • Jake is often in the same room when this is happening

42. Natalie • Natalie is pregnant with her second baby. Her eldest daughter Fleur is 6 years old and has recently become withdrawn and is displaying behavioural problems at school • Natalie is a solicitor. She is married, her husband is a teacher. They are financially stable and have good family support networks • Natalie’s husband subjects her to constant emotional abuse, mocking, name calling - he occasionally physically abuses her

43. Stacey • Stacey is 32 weeks pregnant • She is 16 years old and this is her first pregnancy • She attended labour ward earlier today with a history of diminished fetal movements for the past three days • On reading her medical notes you notice that she had had several previous admissions with urinary tract infection, abdominal pain, diminished fetal movements • Her partner is constantly with her and will often speak for her