WC Leung 梁永昌 Consultant Obstetrician

1. Multidisciplinary Collaboration 10 years of Research on Domestic Violence in Chinese Pregnant Women27 May 2009 WC Leung 梁永昌 Consultant Obstetrician Department of Obstetrics & Gynaecology, Kwong Wah Hospital, HKSAR Honorary Clinical Associate Professor Department of Obstetrics & Gynaecology, University of Hong Kong

2. Antenatal blood tests: blood groups, Hb, MCV, Rh, Rubella antibody, HBsAg, VDRL, HIV Thalassaemia OGTT for GDM Prenatal screening for Down syndrome Routine anomaly scan Screening for postnatal depression (EPDS) Screening programmes for pregnant women in HK Well, this is not my specialty

3. HKJGOM 2001

4. WHO criteria for screeningWilson & Jungner 1968 • The condition sought should be an important health problem for the individual and community • There should be an accepted treatment or useful intervention for patients with the disease • The natural history of the disease should be adequately understood • There should be a latent or early symptomatic stage • There should be a suitable and acceptable screening test or examination

5. WHO criteria for screeningWilson & Jungner 1968 • Facilities for diagnosis and treatment should be available • There should be an agreed policy on whom to treat as patients • Treatment started at an early stage should be of more benefit than treatment started later • The cost should be economically balanced in relation to possible expenditure on medical care as a whole • Case finding should be a continuing process and not a once and for all project

6. HK – Newly Reported Battered Spouse Cases Source: Statistic on child abuse, battered spouse and sexual violence case http://www.swd.gov.hk/vs/english/stat.html

7. HK – Newly Reported Child Abuse Cases

8. ? JPOG 2000

9. IJGO 1999 631 pregnant women were interviewed in the Antenatal Clinic: 17.9% had a history of abuse 15.7% had been abused in the last year 4.3% had been abused during current pregnancy 9.4% had been sexually abused in the last year The husband / partner was the perpetrator in the majority of cases The nature of abuse was mainly psychological / verbal without physical injury Risk factors: unplanned pregnancy, unemployed husband / partner Permanent local residents > new immigrants

10. IJGO 2002 245 women seeking TOP; 256 general gynaecology patients The lifetime prevalence of abuse in the TOP group was 27.3% which was significantly higher than the non-TOP group (8.2%) Most abused victims were unwilling to disclose their information of abuse to their gynaecologists

11. IJGO 2003 500 consecutive women attending the outpatient subfertility clinic The lifetime prevalence of intimate partner violence was 1.8% The quality of life scores (WHO QOL questionnaire – HK version) from the abused victims were significantly lower in the social relationships domain (p=0.012), psychological health domain (p=0.05) and environment domain (p=0.05)

13. The Abuse Assessment Screen (AAS) • Takes 3-5 minutes • The Chinese version has been validated

15. Abuse Assessment Screen (AAS) 1. WITHIN THE LAST YEAR, have you been hit, slapped, kicked, or YES NO otherwise physically hurt by someone? If YES, by whom? ________________ Total number of times ____________ 2. SINCE YOU'VE BEEN PREGNANT, have you been hit, slapped, kicked, or otherwise physically hurt by someone? YES NO If YES, by whom? _____________ Total number of times ________________ MARK THE AREA OF INJURY ON THE BODY MAP SCORE EACH INCIDENTACCORDING TO THE FOLLOWING SCALE: SCORE 1 = Threats of abuse including use of a weapon _______ 2 = Slapping, pushing; no injuries and/or lasting pain _______ 3 = Punching, kicking, bruises, cuts and/or continuing pain _______ 4 = Beating up, severe contusions, burns, broken bones _______ 5 = Head injury, internal injury, permanent injury _______ 6 = Use of weapon; wound from weapon _______ If any of the descriptions for the higher number apply, use the higher number. 3. WITHIN THE LAST YEAR, has anyone forced you to have YES NO sexual activities? If YES, by whom? _____________ Total number of times ________________ http://www.nnvawi.org/

16. The Chinese AAS

17. The Chinese AAS

18. The Chinese AAS

19. The Chinese AAS

20. The Chinese AAS

21. The Chinese AAS

22. IJGO 2001 No difference was found between the abused & non-abused groups in terms of: miscarriages, antepartum haemorrhage, hypertension, antepartum stillbirth, preterm deliveries, mode of deliveries, birthweight, Apgar scores & admission to NICU Multiparous women in the abused group were more likely to deliver female babies (male:female = 3:5, p=0.05) We failed to demonstrate any adverse effect of domestic violence on the pregnancy outcome in our population

23. IJGO 2002 Prospective cohort study on 838 women after delivery 16.9% had been abused in the last year 10.4% had been abused during the current pregnancy 1.7% had been sexually abused in the last year The nature of abuse was mainly VERBAL The socio-demographic factors (except unplanned pregnancy) & standard pregnancy outcome did not differ between the abused & non-abused group The abused group had significantly higher SDSS (Stein’s Daily Scoring System) and EPDS (Edinburgh Postnatal Depression Scale) at: (1) Day 2 or 3 postdelivery; (2) 1-2 days after discharge from hospital; (3) 6 weeks postdelivery

24. IJGO 2005 A total of 1614 OBGYN patients in 4 groups [1. requesting TOP(300), 2. subfertility (500), 3. general gynaecology (300), 4. obstetric (514)] The overall lifetime prevalence of intimate partner violence was 7.2% (12.7%/ 1.8%/ 4.7% / 10.9%) in groups 1 to 4 WHO Quality of Life Measure – abbreviated version (HK) questionnaire The mean QOL domain scores among the abused victims were significantly lower in the physical health domain, social relationship domain, environment domain, and psychological health domain The baseline quality of life of the victims of intimate partner violence is significantly impaired compared with the non-abused controls

29. BJOG In Press The Impact of Psychological Abuse by an Intimate Partner on the Mental Health of Pregnant Women A Tiwari, KL Chan, D Fong, WC Leung, DA Brownridge, H Lam, B Wong, CM Lam, F Chau, A Chan, KB Cheung, PC Ho • 3245 pregnant women were interviewed in the Antenatal Clinics of seven public hospitals • Of the296 (9.1%) pregnant women who reported IPV in the last year: • 216 (73%) reported psychological abuse only • 80 (27%) reported physical and/or sexual abuse • Of the 212 (6.5%) pregnant women who reported IPV since becoming pregnant: • 192 (91%) reported psychological abuse only • 20 (9%) reported physical and/or sexual abuse • Risk factors: being in debt, requiring financial assistance, unplanned pregnancy, and in-law conflict

32. BJOG In Press The Impact of Psychological Abuse by an Intimate Partner on the Mental Health of Pregnant Women A Tiwari, KL Chan, D Fong, WC Leung, DA Brownridge, H Lam, B Wong, CM Lam, F Chau, A Chan, KB Cheung, PC Ho Women in the psychological abuse only group had a higher risk of postnatal depression compared with non abused women (adjusted OR: 1.84, 95% CI: 1.12 - 3.02, p = 0.016) They were also at a higher risk of thinking about harming themselves (adjusted OR: 3.50, 95% CI: 1.49 - 8.20, p = 0.004) and had significantly poorer mental health-related quality of life (P <.001) The higher risks of postnatal depression (adjusted OR: 1.75, P =0.137) and thinking of harming themselves (adjusted OR: 1.17, P =0.861) were not observed in the physical and/or sexual abuse group although significantly poorermental health-related quality of life (P <.001) was observed

35. 110 Chinese pregnant women with history of abuse by their intimate partners Empowerment training (n=55) vs. standard care (n=55) Empowerment training = advice in safety / choice making / problem solving (Parker’s model) + empathic understanding (Roger’s client-centred therapy) Standard care = wallet-sized card with information on community resources for abused women Outcome measures: Conflict Tactics Scale (CTS), health-related quality of life (SF-36), postnatal depression (EPDS) The intervention group had significantly better quality of life, less psychological abuse, less minor physical violence & lower postnatal depression scores

36. Pregnancy: Window of Opportunity Health care setting provides an unique opportunity: Routine assessment on health Experience in making highly personal and sensitive inquiry Trusting relationship

37. The HK Medical Diary 2005 We have a strong belief that pregnancy is an excellent opportunity for screening the early stage of domestic violence (psychological abuse) and effective intervention at this stage can prevent the progression of the severity of violence or even a major family tragedy such as suicide or homicide.

38. The HK Medical Diary 2005 We still have a long way to go not just to prove this hypothesis but also to convince the health policy makers and the public to accept this concept and realize its potential application.

39. The HK Medical Diary 2005 We still have a long way ?? to go not just to prove this hypothesis but also to convince the health policy makers and the public to accept this concept and realize its potential application.

40. Coming……. • Cost measures for the economic impact of domestic violence • Pregnancy as a risk factor of violence against Chinese women • Positive fathering: A programme to enhance the mental health and marital relationship of expectant couples

41. Antenatal blood tests: blood groups, Hb, MCV, Rh, Rubella antibody, HBsAg, VDRL, HIV Thalassaemia OGTT for GDM Prenatal screening for Down syndrome Routine anomaly scan Screening for postnatal depression (EPDS) Domestic Violence or Intimate Partner Violence Screening programmes for pregnant women in HK

42. Multidisciplinary Collaboration 10 years of Research on Domestic Violence in Chinese Pregnant Women Sep/Oct issue 2008

43. HKU Domestic Harmony Research Team UNIVERSITY OF HONG KONG Department of O&G, QMH Prof. PC Ho, Dr. WC Leung Department of Nursing Studies Dr. Agnes Tiwari Dr. Daniel Fong (Principal Statistician) Ms. Janet Wong Department of Social Work & Social Administration Dr. Edward Chan, Ms. Anna Choi Ms. Liu Ting Ting Faculty of Law Dr. Anne Cheung, Ms. Kapai Puja Policy 21 Limited Mr. HK Yip HA HOSPITALS Dr. Robert Chin, Dr. Lawrence Tang, Dr. SK Lam, Dr. WC Leung, Ms. Alice Sham (KWH) Dr. Helena Lam (PMH) Ms. Florence Chau (QEH) Dr. KB Cheung (TMH) Dr. WK To, Dr. Patricia Ip (UCH) Comprehensive Child Development Service Dr. Patrick Ip, Dr. CB Chow UNIVERSITY OF CALIFORNIA, SF Dr. J Humphreys UNIVERSITY OF VIRGINIA Dr. B Parker UNIVERSITY OF MANITOBA Dr. D Brownridge YANGZHOU UNIVERSITY, SCHOOL OF LAW Prof. Li Xiuhua RESEARCH NURSES Joyce Lam, Irene Leung, Peony Wu, Denise Tang, Nancy Tang, Sylvia Tsang, Anita Wong