Violence in Pregnancy Introduction

1. Violence in PregnancyIntroduction Goals: • Identify women/ mothers at risk • Screening practices • Referral and Safety Planning Did you know pregnant women have a higher risk of experiencing violence during pregnancy than they do of experiencing problems such as pre – eclampsia, placenta previa or gestational diabetes? Health Canada, 1999

2. Statistics • Incidence of reported violence in pregnancy is 4 – 17% • Reported DV Cases – 40% of the women said that violence began during pregnancy • 1 in 6 women report the first abuse occurred during pregnancy • Women abused during pregnancy were 4 times as likely as other abused women to say they experienced very serious violence such as beating, choking, gun/knife threats and sexual assault CDC

3. 56% of abused women are between 18 and 34 years of age • 21% of women in Canada who reported abuse by an intimate partner said they were abused during pregnancy IPV Guidelines, British Columbia Reproductive Care Program, 2003 • 95% of women abused in the first trimester were also abused in a three month period after delivery Health Canada, 1999

4. Warning Signs in Pregnant Women • Delayed pre-natal care • Reluctance or refusal to attend pre-natal education • Unexplained bruising – particularly of the breasts and abdomen • Continued use or addiction to substances such as cigarettes, drugs and/or alcohol • Recurring or unexplained psychosomatic illnesses • History of physical illness

5. Identifying Women at Risk • 3 Methods (in a medical setting) • Chart reviews > Injuries consistent with assault • Multiple medical visits • History of drug use, depression or suicide attempts • Eating disorders • Unexplained somatic symptoms including choking sensation • Obstetrical/ gynecological history i.e. spontaneous or elective abortions, STIs, preterm labour or bleeding, low birth weight, unexplained fetal injuries present at birth, unexplained intrauterine fetal demise

6. Direct Questioning/ Screening • “With so many women experiencing abuse during pregnancy, screening for abuse during pregnancy must be a routine part of prenatal care”. Health Canada, 1999 • Recommendation that woman abuse be a topic included on standard forms • BORN – Better Outcome Registry Network – question on data base regarding woman abuse • Paper commissioned by College of Family Physicians of Canada’s Maternity and Newborn Care Committee – (January 2000) “All pregnant women should be screened”.

7. Screening for Abuse • Purpose 1. To identify any abuse experienced by the woman in the past or in the present. 2. Decrease the incidence and prevalence of woman abuse by identifying abuse as a health issue and responding appropriately with effective treatment, documentation and referrals.

8. Research has shown that indicator – based identification for woman abuse is not as effective or consistent in achieving early identification and intervention • Routine universal comprehensive approach avoids stigmatization of abused women. • RUCS Protocol • Routine Screening - Done on a regular basis - Whether or not indicators of abuse are present.

9. Universal Screening - means that every woman over the age of 12 years is routinely asked about her current or past experience of physical, sexual and/or emotional abuse

10. Comprehensive Screening - Means that women are routinely asked about experience or past experience of any form of physical, sexual, and/or psychological abuse as children, adolescents or adults

11. Guiding Principles for Screening A – ATTITUDE and APPROACHABILITY of the health care professional; B – BELIEF in the woman’s account of her own experience of abuse C- CONFIDENTIALITY is essential for disclosure; D – DOCUMENTATION that is consistent and legible; E – EDUCATION about the serious health effects of abuse; and R – RESPECT for the integrity and authority of each woman’s life choices and RECOGNITION that the process of dealing with the identified abuse must be done at her pace, directed by her decisions.

12. Barriers • Stigma of “happy family” • Health care professionals, family and friends may not be open to disclosure • “Rooming In” • Pressure and expectations re. labour and delivery, breastfeeding

13. Health Impact • Abdominal Trauma - Fetal fractures, rupture of the uterus, liver or spleen • Studies show that the attacks are usually targeted at the breasts, abdomen and genitals • Maternal morbidity and mortality • Increased risk of miscarriage, low birth weight, fetal injury and/or fetal death

14. Other Complications • Uterine Prolapse • Antepartum Hemorrhage • Premature rupture of membranes • Premature labour • Abruptio Placenta • Vaginal Infection • Increased 1st and 2nd trimester bleeding • Headache • Irritable Bowel Syndrome • Chronic Pelvic Pain • Increased risk of Sexually Transmitted Illnesses or HIV/AIDS

15. Dynamics of DV • Prenatal • Abuser may control access to care • Concern with partner being overly solicitous, prevents her from seeing the professional in private, does not allow her to answer questions herself • Prenatal classes – abuser may embarrass her, may be rough with the woman, more concerned about what other think than the woman’s comfort • Ridicule and teasing, calling her names such as “cow” or “blimp” • Demanding to know sex of the baby

16. In Labour • Abuser controls decisions regarding epidural, pain medication or other interventions • Disparaging comments regarding her body, and the baby’s sex • Demanding repair/restore the vagina to pre – birth state • Refuses to leave her alone • Complaining about how “all this” affects him

17. After the birth • The abuse may increase and the baby is used as a weapon, he may deny access • Failure to support, sulking, complaining • Demanding sex • Negative comments about appearance • Blame if the baby is “the wrong sex” • Put down her parenting ability • Threaten to or abduct the baby • Make her stay home, prevent her from taking a job • Make or threaten child abuse allegations • Withhold money for supplies

18. Role of Health Care Providers • Be educated about domestic violence • Understand - her reluctance to disclose due to shame, embarrassment, housing and financial issues - she may hope the pregnancy will reform an abusive partner - the pregnancy may be a form of abuse i.e. sexual assault, marital rape, contraception forbidden - unintended or unwanted pregnancy – the woman is 4 times more likely to experience abuse - the pregnancy may be a form of control/ coercion, the abuser’s way to commit the woman to the relationship

19. Ask about abuse • Assess immediate risk • Assist the woman to develop a safety plan • Make referrals to available resources • Follow-up

20. Follow up Women who received, in an empowering manner, a nursing intervention designed to provide them with information on the cycle of violence, a danger assessment, information on the options available to them, safety planning, and resource referrals… • Lower incidence of physical and non physical abuse at six and twelve months after intervention • Used significantly more safety behaviour Parker et al. 1999.