The midwives role in domestic violence

Domestic violence has been with us throughout the ages. A brief overview of the subject shows that it has taken many forms and significantly, we note that the phenomenon is defined in many different ways. To an extent, these ways are determined by the society, the environment and to an extent the chronological time of the events. Acts and behaviour patterns which can be considered acceptable in one social construct can be completely unacceptable in another. We can cite an example enshrined in British law, that up to 1824 a husband was legally entitled to beat his wife to any degree as long as he did not use a stick that was larger in diameter than his thumb, hence giving rise to the expression “rule of thumb” (Boyle A et al. 2004). 

Studies have shown (DOH 2000) that women who are abused experience an average of 35 episodes of domestic violence before they make the decision to seek help. The same study details the many and varied ways that women will ask for help. Some are clearly unequivocal and overt by reporting to the police, the social worker or some other statutory representative or healthcare professional, while others may not present overtly and the signs of abuse may be noticed by another person who then intervenes and may thereby represent a channel of communication that may be what the victim has been waiting for. A third group appear to enter a phase of complete denial. They may present to a healthcare professional with signs and symptoms that are highly suspicious of domestic violence, but when challenged, may deny the possibility and produce a string of plausible explanations as to just how certain injuries had been sustained. (Yura H et al. 1998). As with any situation that affects the human condition there are inevitably a spectrum of other presentations behind these extremes and although we have chosen to present three particular stereotypes, we note that each individual case is unique, has its own unique trigger factors and response patterns, but is almost universally distressing and degrading to the victim of such violence. In the circumstances that we are considering here the case is rather different from the majority insofar as we are specifically considering the role of the midwife in dealing with domestic violence. It follows from this that violence towards the mother not only affects her but potentially can cause both direct and indirect morbidity with the unborn or newborn child. There is also the effect that it can have on any other children in the family, but we shall discuss these issues in greater detail in the review itself.

The whole topic of domestic violence has been given a degree of prominence in recent years with bodies such as the American College of Emergency Physicians (ACEP 1996)  and their British counterpart, the BAEM, (BAEM 1993) 
issuing protocols and guidelines relating to suspected domestic violence and the British Government launching a number of initiatives which are specifically directed at targeting the whole area of domestic violence and also at helping to support the victims of such violence.

Methodology

The method which was adopted for this particular review was to take the initial step of both considering and reflecting on the title, and the implications of the title, for a short period of time and to read through some relevant general literature surrounding the subject in order to get an overview of the whole area. (Dempsey P A et al. 2000).  Shortly after this, further reading was done to encompass the areas of the research patterns that had emerged historically in this area. (Vickers, A. J et al. 2001). This was done over a period of about two weeks and covered about 40 different texts. During this period appropriate references were noted and cited papers were located, read and recorded. Some computer sources including CINAHL, MIDIRS and OVID, together with the Cochrane Data base, were accessed for further background (and in some cases specific)  information. The computer sources were not directly utilised in the preparation of the review itself, as the main basis of the literature used was accessed in hard copy from both the local Post- Graduate centre and also the local University library (client: you might like to personalise this) where the databases for appropriate literature on the subjects could be searched and retrieved together with peer-reviewed journals. (Macnee C L 2004). It should be noted that the majority of papers retrieved and consulted were from UK based peer reviewed journals and UK based authors, but a number were from international sources. As a general rule, the primary searches were done using material that was not more than 10 years old, although some older papers were consulted when it was necessary to put particular points into a historical perspective.  (Rees C 2003)

Approximately 45 papers were both read and assimilated in the preparatory stages of this review, both in the area of domestic violence and in the area of specific midwife involvement in the investigative process. Further papers were read in the area of critical analysis of peer reviewed literature. In total, over 120 papers were consulted in the preparation of this review. The evidence was assembled and assessed in a critical and dispassionate form and them the most relevant portions were presented in a logical fashion in the final review. ( Berwick D  2005)

Having been able to assess and present the available evidence, it then became possible to take a view on the evidence base thus collected, a summary made and conclusions reached. The conclusions and summary were then used to establish where there were gaps in the literature. (Hek G et al. 2000).  This allowed for a number of further conclusions relating to the direction of necessary research in the area.



Review

If we consider the literature on the subject of domestic violence it quickly becomes apparent that the spectrum of domestic violence, at least in terms of definition, is huge. Different papers appear to define and describe the phenomenon in quite different and disparate ways. Boyle (A et al. 2004) details “abuse, intimate partner abuse, interpersonal violence, wife battering, or violence against women” as being some of the terminology that is in common usage for the phenomenon and also highlights the consideration that other terms such as  "wife beating and violence against women"  are also commonly accepted synonyms for the phenomenon but should be regarded as very unsatisfactory for the process in general terms, as it directly implies that the violence is a one way phenomenon from a man directed against a woman. While it is true that this type of assault constitutes the overwhelming majority of cases, one must not overlook the possibility of domestic violence directed against men from their female partners and also against both men and women in homosexual relationships. (Mcleod M 1984).


Another confounding factor which becomes apparent when making any degree of critical appraisal of the literature, is the fact that there appears to be a considerable disparity in the definition of how one can define the perpetrator in domestic violence situations. How, for example, does one categorise the male victim of domestic violence if he is being attacked in retaliation for previous assaults on his wife?  Boyle cites two opposing definitions as an example to illustrate the point. The Coker study (Coker A l et al. 2000) only categorised an incident as “domestic violence” if the perpetrator had been having intimate relations with the victim for more than three months whereas, by contrast the Tham study (Tham S W et al. 1995), defines the perpetrator as “someone who might have been expected to be supportive”. The two definitions being clearly miles apart in terms of reflection of the relationship between the offending parties and thereby making meaningful comparison between papers very difficult.  In the same way we can point to any number of papers which define domestic violence as physical assault where as a significant proportion of what may be more appropriately called domestic abuse may have a psychological, financial or even a purely verbal element in it, but it can still contribute to a significant amount of psychological trauma in the victim of such an arrangement. As we have commented in the introduction there is also the element  of “collateral damage” to other members of the family who may witness domestic violence  even though it may not be directed overtly at them. We shall discuss the “psychological erosion” effect that such witnessing may have on children in the family and how it may appear to “legitimise” this behaviour in their eyes and how it may subsequently manifest itself in a belief that in later life violence is an appropriate ploy to settle intra-family disputes.


If we consider a comparatively recent study by Mirrlees-Black (C 1999), we can point to a substantial evidence base that suggests that domestic violence in the sense of physical violence is more often than not perpetrated by a comparative stranger, the more subtle forms of psychological and financial abuse are more likely to be perpetrated by a “significant other” with a closer and more intimate relationship than overt violence.


If we accept all of these caveats and consider the aetiology of domestic violence in general terms, a number of different authorities point to a number of different factors which appear to be significant in the genesis and perpetuation of the abusive and violent situation. Boyle suggests that controlling behaviour in the perpetrator is significant and Dearwater (S R et al. 1998) suggests a crescendo scenario starting from verbal abuse stemming from a failure of respect on the part of the perpetrator, which can then escalate into one of the other forms of controlling behaviour patterns. Controlling behaviour can be considered as economic control as well as physical control.


For a definitive and considered general statement on the issue we can look to the World Health Organisation who has defined violence as:

...the intentional use of physical force or power, threatened or actual...that either results in, or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation (WHO 1996)



If we consult the literature for an appreciation of the incidence of domestic violence, we immediately face the problem (quite apart from that of actual definition cited above) of knowing the extent of domestic violence that is unreported. Clearly we can cite figures that reflect the number of cases that are reported to the police or are suspected at the A&E departments across the country, as these are figures that are routinely collected and are in the public domain. Abbott (J et al. 1995), in trying to understand the degree of the problem, undertook a large cross sectional study and commented on the reluctance of many victims to disclose significant information. Their study (albeit American based) suggested that 11.7% of women who attended the A&E Depts. included in their study,  were attending because of either injuries or stress directly referable to domestic violence in one of its many forms. Of all the women seen in the A&E Depts., 2% were there as a direct result of physical trauma sustained  directly from an abusive relationship, and this particular study suggests a staggering 54.2% lifetime prevalence rate for domestic violence in the populations of women who were seen in the A&E Depts. during the period of the study. This may well reflect the comments made in the opening paragraph of this review that the degree of domestic violence is as much a factor of the culture of the perpetrator and definition of the act as much as any other factors. This is illustrated  by consideration of a comparison with a similarly constructed UK study (Boyle A A et al. 2003) which found that 1% of women attending the A&E Depts in the study were there as a direct result of direct physical violence and the same authors calculated the overall lifetime prevalence rate for domestic violence in this population to be in the region of 22%.   This second set of figures is more nearly in keeping with the majority of other studies in the area (viz. Dearwater S R et al. 1998).


A smaller Scottish study (Wright J et al. 1997) considered an A&E dept seeing 60,000 cases per year and found 19 cases of overt (incontrovertible) domestic violence in a two month period. Another factor which may be considered to be implicit in the term “domestic violence” is the fact that the violence is considered to have occurred in the home. This is not universally the case. A rather older study (Fothergill N et al. 1990) found that between 15% and 20% of cases of assault occurred at sites away from the victim’s home. One of the overriding factors that must be considered in any type of critical analysis of the figures is that part of the apparent disparity in both incidence and prevalence is due to the structure of the studies. There appears to be a distinct overrepresentation of victims of domestic violence in the populations that present to A&E Depts. If we compare these figures with those obtained from more community based studies such as the British Crime Survey (cited in Mirrlees-Black C 1999) we find that lifetime prevalence figures are in the region of 26% for women and 17% for men and annual prevalence figures in the same study are quoted as 5.9% and 4.9% respectively.


We have made mention of some of the demographic elements earlier. If we consider these in rather more detail, we can point to studies (Roberts G L et al. 1996) which suggest that, (again in a population of A&E Dept attenders), over 15% of men had experienced at least one episode of domestic violence in their lives and this was approximately half that of a similar group of women. Factors that were found to be independent risk factors for the risk of domestic violence include lack of education, alcohol misuse, unemployment, low income, and recreational drug use (Kyriacou D N et al. 1999).


In specific consideration of our investigation in the role of the midwife in the issue of domestic violence, we note that there was a widely reported study which suggested that being pregnant was also an independent risk factor for abuse (Gelles R J 1988). This was considered to be a landmark study in the area at the time of its publication, but we note that other reputable and carefully constructed studies have failed to replicate the original author’s findings. (McGrath M E et al. 1998. Other relevant factors include comparative youth as a risk factor and there are also studies that suggest that post-partum status carries a higher risk of domestic violence than does antenatal status. (Gazmararian J A et al. 1996). The same study also provides evidence to support the view that both the severity and the frequency of attacks of overt physical violence appears to escalate as pregnancy progresses and passes to the post natal period reaching a peak at between 6-9 months post partum.


In terms of identification of the potential victim of domestic violence the midwife (or other healthcare professional) should be alert for a number of signs and symptoms that have a high index of suspicion for domestic violence. (Staquet M J et al. 1998).  Different studies have identified different characteristics of the abused partner but there are a number of common factors which appear to be reasonably consistent throughout the major studies of the subject.



The most common consensus is that the victim will tend to demonstrate an increased usage of healthcare facilities. In general terms Bergman (B et al. 1991) is typical in this regard and documents an increased utilisation of all forms of medical care, most notably hospital admission which were found to be four times higher in this group than the admission rate in the general population.  even though we must accept that in the figure derived for the “general population” there will inevitably be an unknown, but probably significant, number of undetected cases of victims of domestic violence. Intuitive examination of the issue might suggest that there would be an increase in the usage of the psychiatric services and indeed, the same study points to a higher utilisation of facilities that are associated with alcoholism, depression and also deliberate self harm in the victims of domestic violence group. In terms of the index of suspicion for the visiting midwife, the authors suggest that women who present with multisystem, frequent and poorly defined complaints should be regarded as being the most likely to have an underlying problem with domestic violence, even they may not wish to overtly communicate this fact top the healthcare professional, it should be regarded as a significant warning sign.


Other studies point to other warning signs. We have already commented upon the likelihood of repeated attendance being associated with domestic violence, but interestingly, one study. (Spedding R L et al. 1999) suggested that the time of presentation was also significant. For reasons that the authors did not enlarge or speculate on they found that assaulted women were more likely to present between 6 pm and 6 am when compared to those with unintentional injuries.

There is considerable discussion and debate in the literature related to whether these traits and characteristics suggest a causal or resultant relationship between observed symptomatology and the situation of domestic violence. On an intuitive level one can postulate that being the victim of domestic violence or being in a long-term abusive relationship may be sufficient cause to present to a healthcare professional with depression, and could easily lead to episodes of deliberate self harm equally Wadman (M C et al. 1999) considers the possibility that the personality traits that can be frequently associated with both a depressive personality and also the tendency to deliberate self harm, may also “confer an increased risk of entering an abusive relationship”. Examination of the current literature on this element does not help us to reach any clearer view on the issue other than to allow us to present the fact that there is clearly a dichotomy of opinion on the subject.

In specific regard to issues surrounding pregnancy we can also note that there is evidence to suggest that violence can be specifically related to such issues. (CMO 2000). Of all the women who died in a three year period (‘97-’99) with a death related to pregnancy, 12% had reported domestic violence at some stage prior to their death. The study did not make any direct observation (because it couldn’t) of a direct link between domestic violence and the death.

 

 

Methodology

The method which was adopted for this particular review was to take the initial step of both considering and reflecting on the title, and the implications of the title, for a short period of time and to read through some relevant general literature surrounding the subject in order to get an overview of the whole area. (Dempsey P A et al. 2000).  Shortly after this, further reading was done to encompass the areas of the research patterns that had emerged historically in this area. (Vickers, A. J et al. 2001). This was done over a period of about two weeks and covered about 40 different texts. During this period appropriate references were noted and cited papers were located, read and recorded. Some computer sources including CINAHL, MIDIRS and OVID, together with the Cochrane Data base, were accessed for further background (and in some cases specific)  information. The computer sources were not directly utilised in the preparation of the review itself, as the main basis of the literature used was accessed in hard copy from both the local Post- Graduate centre and also the local University library (client: you might like to personalise this) where the databases for appropriate literature on the subjects could be searched and retrieved together with peer-reviewed journals. (Macnee C L 2004). It should be noted that the majority of papers retrieved and consulted were from UK based peer reviewed journals and UK based authors, but a number were from international sources. As a general rule, the primary searches were done using material that was not more than 10 years old, although some older papers were consulted when it was necessary to put particular points into a historical perspective.  (Rees C 2003)


Approximately 45 papers were both read and assimilated in the preparatory stages of this review, both in the area of domestic violence and in the area of specific midwife involvement in the investigative process. Further papers were read in the area of critical analysis of peer reviewed literature. In total, over 120 papers were consulted in the preparation of this review. The evidence was assembled and assessed in a critical and dispassionate form and them the most relevant portions were presented in a logical fashion in the final review. ( Berwick D  2005)


Having been able to assess and present the available evidence, it then became possible to take a view on the evidence base thus collected, a summary made and conclusions reached. The conclusions and summary were then used to establish where there were gaps in the literature. (Hek G et al. 2000).  This allowed for a number of further conclusions relating to the direction of necessary research in the area.



Review

If we consider the literature on the subject of domestic violence it quickly becomes apparent that the spectrum of domestic violence, at least in terms of definition, is huge. Different papers appear to define and describe the phenomenon in quite different and disparate ways. Boyle (A et al. 2004) details “abuse, intimate partner abuse, interpersonal violence, wife battering, or violence against women” as being some of the terminology that is in common usage for the phenomenon and also highlights the consideration that other terms such as  "wife beating and violence against women"  are also commonly accepted synonyms for the phenomenon but should be regarded as very unsatisfactory for the process in general terms, as it directly implies that the violence is a one way phenomenon from a man directed against a woman. While it is true that this type of assault constitutes the overwhelming majority of cases, one must not overlook the possibility of domestic violence directed against men from their female partners and also against both men and women in homosexual relationships. (Mcleod M 1984).


Another confounding factor which becomes apparent when making any degree of critical appraisal of the literature, is the fact that there appears to be a considerable disparity in the definition of how one can define the perpetrator in domestic violence situations. How, for example, does one categorise the male victim of domestic violence if he is being attacked in retaliation for previous assaults on his wife?  Boyle cites two opposing definitions as an example to illustrate the point. The Coker study (Coker A l et al. 2000) only categorised an incident as “domestic violence” if the perpetrator had been having intimate relations with the victim for more than three months whereas, by contrast the Tham study (Tham S W et al. 1995), defines the perpetrator as “someone who might have been expected to be supportive”. The two definitions being clearly miles apart in terms of reflection of the relationship between the offending parties and thereby making meaningful comparison between papers very difficult.  In the same way we can point to any number of papers which define domestic violence as physical assault where as a significant proportion of what may be more appropriately called domestic abuse may have a psychological, financial or even a purely verbal element in it, but it can still contribute to a significant amount of psychological trauma in the victim of such an arrangement. As we have commented in the introduction there is also the element  of “collateral damage” to other members of the family who may witness domestic violence  even though it may not be directed overtly at them. We shall discuss the “psychological erosion” effect that such witnessing may have on children in the family and how it may appear to “legitimise” this behaviour in their eyes and how it may subsequently manifest itself in a belief that in later life violence is an appropriate ploy to settle intra-family disputes.


If we consider a comparatively recent study by Mirrlees-Black (C 1999), we can point to a substantial evidence base that suggests that domestic violence in the sense of physical violence is more often than not perpetrated by a comparative stranger, the more subtle forms of psychological and financial abuse are more likely to be perpetrated by a “significant other” with a closer and more intimate relationship than overt violence.


If we accept all of these caveats and consider the aetiology of domestic violence in general terms, a number of different authorities point to a number of different factors which appear to be significant in the genesis and perpetuation of the abusive and violent situation. Boyle suggests that controlling behaviour in the perpetrator is significant and Dearwater (S R et al. 1998) suggests a crescendo scenario starting from verbal abuse stemming from a failure of respect on the part of the perpetrator, which can then escalate into one of the other forms of controlling behaviour patterns. Controlling behaviour can be considered as economic control as well as physical control.


For a definitive and considered general statement on the issue we can look to the World Health Organisation who has defined violence as:

...the intentional use of physical force or power, threatened or actual...that either results in, or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation (WHO 1996)



If we consult the literature for an appreciation of the incidence of domestic violence, we immediately face the problem (quite apart from that of actual definition cited above) of knowing the extent of domestic violence that is unreported. Clearly we can cite figures that reflect the number of cases that are reported to the police or are suspected at the A&E departments across the country, as these are figures that are routinely collected and are in the public domain. Abbott (J et al. 1995), in trying to understand the degree of the problem, undertook a large cross sectional study and commented on the reluctance of many victims to disclose significant information. Their study (albeit American based) suggested that 11.7% of women who attended the A&E Depts. included in their study,  were attending because of either injuries or stress directly referable to domestic violence in one of its many forms. Of all the women seen in the A&E Depts., 2% were there as a direct result of physical trauma sustained  directly from an abusive relationship, and this particular study suggests a staggering 54.2% lifetime prevalence rate for domestic violence in the populations of women who were seen in the A&E Depts. during the period of the study. This may well reflect the comments made in the opening paragraph of this review that the degree of domestic violence is as much a factor of the culture of the perpetrator and definition of the act as much as any other factors. This is illustrated  by consideration of a comparison with a similarly constructed UK study (Boyle A A et al. 2003) which found that 1% of women attending the A&E Depts in the study were there as a direct result of direct physical violence and the same authors calculated the overall lifetime prevalence rate for domestic violence in this population to be in the region of 22%.   This second set of figures is more nearly in keeping with the majority of other studies in the area (viz. Dearwater S R et al. 1998).


A smaller Scottish study (Wright J et al. 1997) considered an A&E dept seeing 60,000 cases per year and found 19 cases of overt (incontrovertible) domestic violence in a two month period. Another factor which may be considered to be implicit in the term “domestic violence” is the fact that the violence is considered to have occurred in the home. This is not universally the case. A rather older study (Fothergill N et al. 1990) found that between 15% and 20% of cases of assault occurred at sites away from the victim’s home. One of the overriding factors that must be considered in any type of critical analysis of the figures is that part of the apparent disparity in both incidence and prevalence is due to the structure of the studies. There appears to be a distinct overrepresentation of victims of domestic violence in the populations that present to A&E Depts. If we compare these figures with those obtained from more community based studies such as the British Crime Survey (cited in Mirrlees-Black C 1999) we find that lifetime prevalence figures are in the region of 26% for women and 17% for men and annual prevalence figures in the same study are quoted as 5.9% and 4.9% respectively.


We have made mention of some of the demographic elements earlier. If we consider these in rather more detail, we can point to studies (Roberts G L et al. 1996) which suggest that, (again in a population of A&E Dept attenders), over 15% of men had experienced at least one episode of domestic violence in their lives and this was approximately half that of a similar group of women. Factors that were found to be independent risk factors for the risk of domestic violence include lack of education, alcohol misuse, unemployment, low income, and recreational drug use (Kyriacou D N et al. 1999).


In specific consideration of our investigation in the role of the midwife in the issue of domestic violence, we note that there was a widely reported study which suggested that being pregnant was also an independent risk factor for abuse (Gelles R J 1988). This was considered to be a landmark study in the area at the time of its publication, but we note that other reputable and carefully constructed studies have failed to replicate the original author’s findings. (McGrath M E et al. 1998. Other relevant factors include comparative youth as a risk factor and there are also studies that suggest that post-partum status carries a higher risk of domestic violence than does antenatal status. (Gazmararian J A et al. 1996). The same study also provides evidence to support the view that both the severity and the frequency of attacks of overt physical violence appears to escalate as pregnancy progresses and passes to the post natal period reaching a peak at between 6-9 months post partum.


In terms of identification of the potential victim of domestic violence the midwife (or other healthcare professional) should be alert for a number of signs and symptoms that have a high index of suspicion for domestic violence. (Staquet M J et al. 1998).  Different studies have identified different characteristics of the abused partner but there are a number of common factors which appear to be reasonably consistent throughout the major studies of the subject.



The most common consensus is that the victim will tend to demonstrate an increased usage of healthcare facilities. In general terms Bergman (B et al. 1991) is typical in this regard and documents an increased utilisation of all forms of medical care, most notably hospital admission which were found to be four times higher in this group than the admission rate in the general population.  even though we must accept that in the figure derived for the “general population” there will inevitably be an unknown, but probably significant, number of undetected cases of victims of domestic violence. Intuitive examination of the issue might suggest that there would be an increase in the usage of the psychiatric services and indeed, the same study points to a higher utilisation of facilities that are associated with alcoholism, depression and also deliberate self harm in the victims of domestic violence group. In terms of the index of suspicion for the visiting midwife, the authors suggest that women who present with multisystem, frequent and poorly defined complaints should be regarded as being the most likely to have an underlying problem with domestic violence, even they may not wish to overtly communicate this fact top the healthcare professional, it should be regarded as a significant warning sign.


Other studies point to other warning signs. We have already commented upon the likelihood of repeated attendance being associated with domestic violence, but interestingly, one study. (Spedding R L et al. 1999) suggested that the time of presentation was also significant. For reasons that the authors did not enlarge or speculate on they found that assaulted women were more likely to present between 6 pm and 6 am when compared to those with unintentional injuries.

There is considerable discussion and debate in the literature related to whether these traits and characteristics suggest a causal or resultant relationship between observed symptomatology and the situation of domestic violence. On an intuitive level one can postulate that being the victim of domestic violence or being in a long-term abusive relationship may be sufficient cause to present to a healthcare professional with depression, and could easily lead to episodes of deliberate self harm equally Wadman (M C et al. 1999) considers the possibility that the personality traits that can be frequently associated with both a depressive personality and also the tendency to deliberate self harm, may also “confer an increased risk of entering an abusive relationship”. Examination of the current literature on this element does not help us to reach any clearer view on the issue other than to allow us to present the fact that there is clearly a dichotomy of opinion on the subject.

In specific regard to issues surrounding pregnancy we can also note that there is evidence to suggest that violence can be specifically related to such issues. (CMO 2000). Of all the women who died in a three year period (‘97-’99) with a death related to pregnancy, 12% had reported domestic violence at some stage prior to their death. The study did not make any direct observation (because it couldn’t) of a direct link between domestic violence and the death.
Although not specifically in the direct province of the midwife, one can also consider the effects of domestic violence on other family members. Such studies are clearly difficult to construct and conduct as the element of denial and the element of secrecy will obviously be large and significant confounding factors in any investigation or statistical analysis. (Mohammed, D et al. 2003).


  
Studies such as that by Berrios (D C et al. 1991) shows strong circumstantial evidence that children who are brought up in situations with physically violent parents have a greater incidence of suffering direct physical abuse from either or both of their parents. We shall return to this point later, but observe that this knowledge puts a further obligation upon healthcare professionals in general to try to predict and detect domestic violence, not only from the point of view of the direct victims, but also from the viewpoint of the peripheral or indirect victims as well.


The psychopathology of the perpetrators (and to a lesser extent the victims) of domestic violence is examined in the thought provoking paper by Zink (T et al. 2004). This paper considers the features of medical management of the perpetrators, which is not particularly relevant to our considerations here. What is of  far greater relevance is the section of the paper where the authors consider the mechanisms whereby the offenders come to a position where they indulge in domestic violence. This gives the healthcare professional a useful insight into the possible dynamics of the situation. (Fawcett J 2005)


In terms of the victim coming to the stage where they feel that support and action is necessary, the authors identify a five stage model of change which is clearly heavily based on the trans theoretical model. (Prochaska  J O et al. 1992). They enumerate the five stages as :
pre-contemplation, contemplation, preparation, action, and maintenance.


As the patient considers their predicament, they will tend to oscillate or cycle through these stages often finding that they move repeatedly between the stages of contemplation, action and maintenance. (Prochaska J O et al. 1994)    



This model of the  stages-of-change closely matches modifications in attitude and behaviour with the tools that are used by the individual when trying to alter his or her behaviour. Prochaska identified 10 tools that are cognitive-affective or behavioural activities which are relevant to these considerations. The cognitive-affective tools (including consciousness-raising, dramatic relief, self-re-evaluation) are used during precontemplation and contemplation. Behavioural tools however, are typically used in the action and maintenance stages. Using the right tool for each stage is important. Many of these changes are equally applicable to the psychopathology of the perpetrator who also appears to move through the same phases. The authors suggest that they tend to be more impulsive however, and the time spent in each stage may be very short indeed. In the light of our examination here, we should note that we can find no study that has examined the victim’s perception of the healthcare professional’s management of the situation with reference to the particular stage of the transition that they are in. Intuitively it would seem likely that the strategies that may be appropriate when the victim is in the contemplative stage are likely to have a different degree of effectiveness when employed in the action stage.


The authors reflect on the fact that there are a great many factors that may well be relevant in any one individual victim’s process of abuse management. This is the one area where the victim of domestic violence has a degree of control as to just how they respond to abusive behaviour. It therefore appears to be very important, from the viewpoint of effective management, that the healthcare professional involved maximises any degree of positive resolve with an empathetic exploration of the relevant issues as far as they are perceived by the patient themselves.


The role of the midwife is, in part, that of Health Promotion facilitator. (Hewison, A. 2004). The midwife has traditionally taken an active role in areas such as teenage pregnancy, smoking cessation, drug awareness. (Ramsey J et al. 2002)   Perhaps we should now consider adding to that list domestic violence as well. We note that the term, and indeed the concept, of Health Promotion, should be synonymous with work that encourages healthy behaviour in the widest possible sense of the word and is therefore complimentary to the more traditional concepts of the healthcare professionals managing disease and ill health. The paper by Beldon (A et al. 2005) considers this issue from the health promotion viewpoint. The authors point to the midwife as being a pivotal professional in terms of a healthcare professional contact for many women in their younger adult lives, when domestic violence is at its peak incidence and also when childbearing is at its most prevalent.


The authors assert that the concept of empowerment and education (Howe and  Anderson  2003) should be at the forefront of the midwife’s agenda and this will act as a bridge to build up trust and a working relationship that can help to detect domestic violence when it occurs and then to help support the victim with appropriate intervention and agency notification.  Although as a concept paper, this is eloquently presented and rationally considered, one is left with the thoughts that a more critical analysis of the message of this paper could be that, as altruistic as these particular aims are, in the current structure of the NHS it is difficult to see how a midwife could actually embrace all of the different concepts and activities that this paper suggests. This is not meant to imply that one should not aspire to achieve all that is suggested, but may indicate the fact that in order to achieve a more public health orientated service, then more protected time may be required to allow the midwife to fulfil all of these functions. In fairness, the paper includes a comment that appears to recognise the fact that change is necessary by exhorting midwives in general to “seek to respond positively to service changes to achieve the goal of multidisciplinary, non-hierarchical patient-centred services. In facilitating change midwives should seek to use their influence to the benefit of the pregnant woman.”


The paper by Taket (A et al. 2003) is another overview concept paper which rehearses many of the arguments that we have presented elsewhere in this review, but it is noteworthy for the fact that it devotes a considerable amount of energy in the examination of the role of domestic violence on the children and points to the fact that the midwife may have her suspicions aroused by the behaviour patterns of affected children even if she has not considered the possibility of domestic violence in relation to the mother’s behaviour or presentation.


The authors point to the fact that some studies (viz.Humphreys C et al. 2002) suggest that  children who are living in a house where domestic violence is active are 30 - 60% more likely to experience child abuse (the paper does not specify physical abuse, but abuse in the wider sense). They are more likely to present with neurotic types of problems including sleep disturbance, poor school performance, emotional detachment, stammering, suicide attempts, and aggressive and disruptive behaviour. The relevance of any of these factors should be regarded as firstly an indicator for the midwife to actively consider making direct, but sensitive, enquiries in relation to domestic violence, as well as making sure that the affected children are referred to the appropriate agency in order that these traits may be actively investigated and treated. The paper also makes the very valid and fundamental point that children who witness domestic violence learn to accept that violence is an appropriate mechanism for resolving conflict and that these behaviour patterns are likely to manifest themselves in these individuals as they grow into adulthood. (Hague G et al. 1998). They make no comment about the intuitive possibility that children who suffer or observe domestic violence may also have a higher incidence of neurotic traits in adult life.





If we now consider specific papers that target the phenomenon of domestic violence in specific relation to pregnancy, we can start with the paper by Mezey (G C et al. 1997). This is an attempt to provide an overview of the area, which it certainly does, but it has to be observed that the papers that it cites, although undoubtedly worthy, are not particularly representative of the whole spectrum of the available literature on the subject. One of the reasons that we have presented a long preamble prior to reviewing specific papers, is the fact that we have been at pains to consider a wide spectrum of authoritative opinion in this area. The comments that the paper makes that domestic violence is reported by up to 25% of women in the Britain, is demonstrably misleading. The paper it cites for this bold statement is the Mooney paper (Mooney J 1993). The major stumbling block here is that the paper itself is a well constructed study, but the entry cohort was women known to the social services in Islington. It is clearly a major error of judgement to try to extrapolate this figure to be representative of the women of Britain in general. There are a number of similar methodological errors in the paper but the reason that we have selected it for inclusion here is the fact that it specifically examines the literature of domestic violence relating to pregnancy. In addition to many of the points that we have already raised in terms of the demography and aetiology of domestic violence, the paper cites convincing evidence that the risk of domestic violence is enhanced by pregnancy with severe attacks being the most common in the post-partum period. It is both interesting, and possibly significant, to note that one paper that is repeatedly cited is the Hilberman paper of 1978. (Hilberman E et al. 1978). This is a particularly interesting paper as it is written from the author’s viewpoint that women who suffer domestic violence are often compliant victims. It puts forward anecdotal evidence to suggest that some women in abusive relationships will often actually try to become pregnant in an attempt to protect themselves from further attack. The authors cite the fact that women who are both pregnant and victims of domestic violence, are much more likely to describe their pregnancy as unplanned and unwanted. It seems clear that any analytical assessment of these two concepts would suggest that they are mutually exclusive. In any event it would appear that the situation, if contrived, is more likely to generate further violence than to protect against it. The authors do not specifically suggest the hypothesis, but it would seem to support those who argue that certain women are actually more secure in an abusive relationship. (Gazmararian J A et al. 1995). We can make no comment on this point other than it seems to be made in the absence of any convincing evidence base.


A very significant feature of this paper, and certainly one that does appear to have a far more secure evidence base than some of the other statements that we have examined, is the section which deals with the complications of domestic violence in the pregnant state. The paper makes the self evident, but yet very relevant, observation that domestic violence during pregnancy places in jeopardy the health and safety of two individuals rather than the one that would be the case in the non-pregnant state. It points to the fact that domestic violence is associated with an increased risk of “miscarriage, premature birth, low birth weight, chorioamnionitis, foetal injury, and foetal death”. It cites a number of sources for this information (including the Hilberman paper) but the quote is largely lifted directly from the entirely reputable Berenson paper (Berenson A B et al. 1994). The difficulty in producing statistically significant and reliable data to back up the degree of risk is considerable because, as Berenson points out, the very factors that are known to be associated with domestic violence, such as increased drug and alcohol use together with an increased incidence of smoking, are also the very factors that are associated with increased foetal morbidity and mortality in any event. (Webster J et al. 1996).


Other significant factors are also explored in this particular section of the paper including the fact that the authors suggest that the foetus may be indirectly harmed by the fact that abused women may be (either directly or indirectly) prevented from seeking adequate ante-natal and post-natal advice and care by their abusive partners. (Norton L B et al. 1995). We shall return to a different significance of this point later.


Interestingly, the authors open up a discussion on the current status of the health care policies in the UK in relation to domestic violence. They point to the fact that the recent changes in both the practice of obstetrics and midwifery (which are said to enhance the ability of the healthcare professionals to provide empowerment and education for the pregnant women and to “demedicalise child birth” (authors term)), are the very changes that may have reduced the possibility of effective intervention. This is a bold statement, as it cites, for support, the fact that the “traditional refuge of the women-only status of the antenatal wards and the labour suite is disappearing”. it points to the fact that the antenatal clinics are noisy and busy places where a woman is less likely to share her problems with the healthcare professionals particularly if, in the words of the authors, they may be considered difficult, shameful, and risky. They do make a very valid observation that the era of hand held patient notes is indeed a counterproductive element simply because confidential documentation is recorded in a situation where it is no longer confidential and available to all who handle the notes. this can clearly be the abusive spouse if the victim is in a particularly controlling relationship. The paper observes that:

There should be greater awareness of the problem, improved identification techniques, and education about available social and legal interventions and the importance of liaison between agencies.


Sadly it does not make any suggestion to effect such changes.



If we consider the question of screening for domestic violence and the issues of how should the midwife most effectively utilise her time in this regard, we can consider the detailed paper by Clarke (K A et al. 2000) which specifically addresses the issue in great detail. One point that has not been previously raised in this context is that a past history of abuse in the post partum period in a previous pregnancy is associated with a 90% risk of abuse during a current pregnancy. (Stewart D E 1994). Interestingly the paper does not specify that the victim has to be with the same partner for this statistic to apply. This could, of course be an oversight, but if it is genuinely true for any partner, then this fact does add credence to the point raised earlier, that some women do tend to become selectively involved in abusive relationships.


The paper starts with the preamble of the at risk groups which we have rehearsed above and therefore will not repeat. The paper makes the comment that even taking into account all of the available strong risk factors, there is still a large cohort of women who are either abused or subject to domestic violence and are not suspected or detected by the healthcare professionals. They suggest that the midwife is ideally placed to screen for less obvious markers and indices that may allow for more cases of domestic violence to be identified, assessed and referred to appropriate intervention agencies. The authors therefore build a case for universal screening for partner violence to be a normal part of ante-natal care. In order to provide a secure evidence base for this case, the authors cite papers such as those by Covington and Wiist (Covington D L et al. 1997) (Wiist W H et al. 1999).



The Wiist paper details the American experience of ante-natal screening and both point to the fact that screening can significantly increase the prevalence of disclosure. Other papers are cited in support of the contention that abused women are actually relieved to be empowered and invited to discuss their problems with domestic violence and are happy to be “given permission” to speak openly about it. (Gerbert B et al. 1999). The authors also point to the fact that although healthcare professionals in the field of obstetrics and gynaecology are more likely to screen for partner violence than many other specialties, there is evidence that this specifically is not the case in the ante-natal clinics. While this may be true, we note that the studies cited all rely exclusively on information that is obtained from providers and not directly from the patients. We can therefore only hazard a guess as to the degree of transferable validity that the results impart.


The Clarke paper then details their study which considered a qualitative assessment of those women who were screened for domestic violence contrasted against those who were not. The entry cohort was impressive with over 2,500 women responding to the study. We will not discuss the methodology of the study in detail, as it is set out in extraordinary detail in the paper itself. But the significant findings do merit further discussion. Factors which triggered healthcare professionals to ask screening questions were found to include being unmarried, those with a poor education and being from an ethnic minority. Unemployment was three times more likely to result in questions relating to domestic violence than being employed and being on benefit produced similar odds. The other significant factor in screening was to be under the age of 20 yrs.


Despite the observations that we have made elsewhere in this review about partner violence being a salient factor in the ability of the expectant mother to access appropriate ante-natal care, in this study it was apparent that those mothers who had fewer attendances at the ante-natal clinic were less likely to receive screening than those who came regularly. Specifically the study found that those women who did not receive any ante-natal care in the first trimester had twice the odds of reporting a violent relationship when eventually questioned.


In common with many of the papers reviewed here, the authors finish this particular paper with a plea for further research in the area and significantly they suggest that there is a need for a determination as to which screening methods are actually helpful in the management of the victim of domestic violence or whether other more effective screening methods are actually required. Despite its initial promise and the title “Who Gets Screened During Pregnancy for Partner Violence”, it actually dose little more than detail the shortcomings of the system and quantifies which patients are actually screened. It is left to the reader to draw their own conclusions about whether these groups are actually appropriate fro screening.


Another area of interest which we can consider in this context, is the mechanism by which the victim of domestic violence becomes able to feel confident in disclosing their problems to the midwife or other healthcare professional. Boyle (Boyle A A et al. 2003) give the advice that :

Simple, direct, non-judgemental questions are the best way to inquire about domestic violence if this is felt appropriate.


Having enquired about the subject and raised the spectre of domestic violence, then one must have a mechanism of assessing the risk. There are a number of appropriately validated tools for this purpose and we shall examine some of them. The paper by Peralta (R L et al. 2003) considers the use of the conflict tactics scale (CTS). This has been relied on in a number of studies as an accurate and reproducible measure of domestic violence particularly in the primary care setting. It appears to demonstrate a high degree of  validity, sensitivity, specificity, and predictive values in these populations. (Newton R R et al. 2001). The authors of this particular study compared the response of the CTS to the simple question “Do you feel safe at home?” and found it to be virtually as specific. It would therefore seen reasonable to regard the latter as a non-threatening opening gambit for the healthcare professional who wishes to explore the area of domestic violence with a patient.   


The Index of Spouse Abuse (ISA) is a rather older measure (Hudson W W et al. 1981), and has therefore been available for validation for a longer period. Although it has proved to be a valid and valuable measure in its time, it has, to a large extent, been eclipsed by the Partner Violence Scale (PVS). The PVS has proved to be the most widely and generally adopted tool in the clinical situation, although all three are still used in research situations, which is fortunate as it still allows direct comparisons to be made between newer and older papers in similar terms.


Although the Hudson paper was primarily relating to the validation and use of the ISA, we note a comment towards the end that is distinctly relevant to our considerations here and that is that the authors noted that, while they were making their evaluations relating to the ISA, the women who were the victims of domestic violence were more likely to disclose their history of abuse to female staff despite male staff asking the same number of questions to a similar number of patients. Again, this appears to be yet another argument in favour of the midwives being active agents in the need for questioning in this area


Conclusions


The whole area of the literature surrounding domestic violence appears, on first examination to be full of apparently conflicting evidence. More careful appraisal of the literature suggests that this apparent confusion and conflict is more a product of varying and imprecise definitions together with a reiteration of figures taken from one study being inappropriately quoted out of their original context in another. (Piantadosi S. 1997). Inevitably this leads to further confusion and possibly the derivation of inappropriate conclusions. In this review we have cited specific examples of this and other methodological errors which appear to blight this subject more than many others.


What we can derive from a critical appraisal of the available evidence is the fact that domestic violence is a real and pernicious problem affecting a significant number of people in the community. The majority of these are women and a significant number are pregnant. Many are comparatively young, being in the under 20 age range. Pregnancy appears to have an association with domestic violence. Opinions vary as to whether the pregnancy causes stress in the domestic home or whether there is an element that the woman who is abused seeks to become pregnant as a form of protection. In any event, the observed facts seem to support the view that there is an escalating crescendo of violent attacks as pregnancy progresses and this phenomenon extends into the post-natal period.


The midwife is therefore ideally placed to act as the frontline healthcare professional in this vulnerable group. We have discussed evidence that shows that the number of women who will present de novo in these circumstances is only a small proportion of the total number of women who suffer domestic violence. Expecting a woman who may regard her problem with a degree of shame and guilt or even denial to present her difficulties in a busy ante-natal clinic when details may be recorded in hand-held records with no confidentiality is clearly doomed to failure in the vast majority of cases. The direct implication of this statement is that in order to try to make inroads into the current situation and try to extend appropriate help to these women, positive steps must be taken in order to actively enquire and seek them out, partly by constructing situations that are conducive to their being able to talk freely and by some form of active enquiry or screening.



Many of the papers that were read for the purpose of this review, have pointed to the fact that the typical woman who gets asked about such factors does not display the noted characteristics of the woman who suffers from domestic violence. One of the independent risk factors for domestic violence has been shown to be an inability (or possibly unwillingness) to access health care facilities. This results in fewer opportunities for appropriate questions to be asked and also it has been shown that this group tend to be asked less in any event.


The only way forward to provide help for victims of such circumstances is to enable those who need help to receive it. The midwife can play a crucial role in this regard. By virtue of her position as a trusted healthcare professional, she is immediately invested with a degree of authority and professionalism in the perception of the patient. This allows her to often be the recipient of otherwise confidential information. As part of the healthcare team she has either direct or indirect access to agencies who can provide help. As the patient’s advocate (Marks-Moran & Rose  1996) she can speak up for the patient who might, for psychological or practical reasons, be unable to look after their own interests. The midwife is also ideally placed to make enquiries either directly, or if considered more appropriate, over a period of time. Her relationship with the pregnant woman is often such that a close bond will develop over the 9 - 10 months that they are in contact. This can be exploited by the midwife to gently explore the possibility of domestic violence if a direct or forthright approach is considered inappropriate.


The issue of screening has been examined at some length in this review. It seems clear that the normal process of examination and history taking does not give sufficient insight into the possibility of domestic violence. A number of studies have suggested that screening should be carried out on every patient who attends the A&E Dept. on the evidence base that a higher proportion of patients who attend this department are more likely to have been victims of domestic violence. While this may be both true and laudable, one has to consider the practicalities of such a measure. One also has to bear in mind that as horrifying and debilitating as domestic violence undoubtedly is, it is only one of a spectrum of social problems that present to healthcare professionals, many of which could equally well also be the subject of papers calling for screening for their particular niche in the spectrum of human behaviour. It is clearly impractical for any healthcare professional to realistically consider screening for everything that could conceivably have occurred as this takes away the focus of what brought the patient to the department in the first place. It is generally accepted that part of the skill of clinical practice is to be both empathetic and alert to relevant cues as they are presented to the clinician and then to follow them up and act upon them as appropriate. (Meleis A. 1991). This statement should not be interpreted as decrying the overall concept of the holistic approach to the patient, but more of a pragmatism that one has to consider what is the best that one can do in any given set of circumstances.


Perhaps the most measured and considered response to the problem comes from the Dept. of Health in the UK who recommends that "routine enquiry"—that is, screening—for all women, should be considered by healthcare professionals (DOH 2000). We note the inclusion of the word “considered”. This is notably absent in USA based guidelines which advocate screening for every patient in this regard.



The down side to these arguments that we have rehearsed in this review, is that it is still not clear whether we, as healthcare professionals, actually have sufficient knowledge about the natural history of domestic violence to institute screening programmes in any event. It is certainly clear that we do not know enough about the overall effectiveness of either the organisations (both statutory and voluntary) or the methods used to combat domestic violence or to help the victims. An overview of the literature on this subject suggests that one major shortfall of most of the published studies in this area, is that they do not consider the reduction of exposure to violence as an outcome. Intuitively one would imagine that many of the victims would consider a reduction in their exposure to a violent partner to be a positive outcome in itself.


We also have to consider that the organisations that currently deal with many of the cases of domestic violence (at least in the UK), are charitable institutions. If one was to impose a mandatory screening programme it is likely that such services might be easily overwhelmed. The consequences of screening are therefore much wider than simply instituting a programme for clinicians to adopt. There is also the added problem that if a healthcare professional identifies domestic violence, and therefore presumably sets in motion a train of events that is aimed at combating it, then this, in turn, may actually provoke more violence in the domestic situation by way of retaliation. Clearly this issue needs to be addressed before any other interventions are considered in isolation.


Despite all of these caveats, it is clear that any healthcare professional, and in the context of this particular examination, the midwife in particular, should be empowered by both ability and knowledge, to create the types of situations that make disclosure of victim status more easy for the wavering patient so that those patients who do disclose such information can be offered help that is appropriate for their particular situation. Practically and conceptually, this is quite a different approach to the imposition of screening and is perhaps more in tune with the Dept. of Health guidelines set out above.


The provision of small private consultation rooms where the midwife can be alone with the patient is very empowering for the patient, (Newell and Simon. 1992), but one has also to consider the effect of the current trend to invite the partner of the pregnant woman to attend all aspects of the antenatal programme. This can clearly be quite counterproductive in the abusive situation. Mandatory exclusion of the partner, although possibly more advantageous in this particular circumstance, would clearly be equally counterproductive in the majority of cases where a couple consider that the process of bringing a baby into the world is a joint venture to be experienced and shared by both.


In terms of the mechanism of enquiry it would appear that simple non-judgemental questions are the preferred and most effective option for the healthcare professional if such enquiry is deemed to be appropriate. We have considered the various tools that are available (PVS, ISA and CTS) and they have been validated as capable of producing statistically valid results. Some are older than others. There is some evidence that a simple question such as “Do you feel safe at home?” provides a useful mechanism for the midwife to establish an entry into this area if suspicions are aroused and is at least as useful in detecting evidence to support domestic violence as any of the other more formal screening tools.


The biggest gap in the literature appears to be in this area.  A great many papers suggest that screening for domestic violence is a useful thing to do in order to establish some form of public health based offensive on abuse happening in the home. From a humanitarian point of view there can be few who would take exception to this stance. Not only does one try to identify the victim and make them safe and free from fear, but also there is (in this particular consideration) the unborn child, the neonate or the other children in the family to consider and the possible morbidity associated with them. The difficulty appears to arise in that we cannot establish any significant evidence base for the effectiveness of the interventions that are available one the situation is adequately identified. To remove the victim to a place of safety may well be an appropriate short term measure, but there are few other measures available to help the victim escape from the often relentless circle of vulnerable personality, economic dependence, substance abuse and victim status, that is all too often seen in association with the domestic violence scenario.  Substantial searching on this subject failed to reveal any significant validated research to suggest how may victims who had been through the “escape mechanism” of refuge accommodation and finished up by re-entering an abusive relationship - either the same one or with a different partner. This is clearly a critical factor when one considers the recommendation of expenditure of effort in the area of even detection.





References 



Abbott J, Johnson R, Koziol-McLain J, et al.  1995
Domestic violence against women: Incidence and prevalence in an emergency department population.
JAMA 1995 ; 273 : 1763-7


ACEP 1996
American College of Emergency Physicians. Emergency medicine and domestic violence.
Dallas: American College of Emergency Physicians, 1996.



BAEM 1993
British Association for Accident and Emergency Medicine: academic committee. Domestic violence: recognition and management in accident and emergency. London : BAEM, 1993.


Beldon A M and Suzanne Crozier 2005
Health promotion in pregnancy: the role of the midwife
The Journal of the Royal Society for the Promotion of Health, Sep 2005 ; 125 : 216 - 220.


Berenson A B, Wiemann C M, Wilkinson G S, Jones W A, Anderson G D. 1994
Perinatal morbidity associated with violence experienced by pregnant women. Am J Obstet Gynecol 1994 ; 170 : 1760-9.


Bergman B, Brismar B.  1991
A 5-year follow-up study of 117 battered women.
Am J Public Health 1991 ; 81 : 1486-9


Berrios D C, Grady D.  1991
Domestic violence: Risk factors and outcomes.
West J Med 1991 ; 155 : 133-5.


Berwick D. 1996
A primer on the improvement of systems.
BMJ 1996 ; 312 : 619-622


Boyle A A, Todd CJ.  2003
Domestic violence in a UK emergency department: an incidence and prevalence survey.
Emerg Med J 2003 ; 20 : 438-42


Boyle A A, S Robinson, and P Atkinson 2004
Domestic violence in emergency medicine patients
Emerg. Med. J., Jan 2004 ; 21 : 9 - 13.


Clarke K A, Martin S L, Petersen R, Cloutier S, Covington D, Buescher P, Beck-Wraden M 2000
Who Gets Screened During Pregnancy for Partner Violence?
Arch Fam Med. 2000 ; 9 : 1093-1099.


CMO 2000
Chief Medical Officer.
Report on confidential enquiries into maternal deaths in the United Kingdom 1997-1999
HMSO : London 2000


Coker A L, Derrick C, Lumpkin J L.  2000
Intimate partner violence among men and women - South Carolina 1998. MMWR 2000 ; 49 : 691-4.


Covington D L, Diehl S J, Wright B D, Piner M.  1997
Assessing for violence during pregnancy using a systematic approach.
Matern Child Health J. 1997 ; 1 : 129-133.


Dearwater S R, Coben J H, Campbell J C, et al.  1998
Prevalence of intimate partner abuse in women treated at community hospital emergency departments.
JAMA 1998 ; 280 : 433-8


Dempsey P A, Dempsey A D  2000
Using Nursing Research. Process, Critical Evaluation and Utilisation. (5th ed) Philadelphia, Lippincott. 2000


DOH 2000
Department of Health. Domestic violence: a resource for healthcare professionals.
London : HMSO, 2000.


Fawcett J 2005
Contemporary Nursing Knowledge: Analysis and Evaluation of Nursing Models and Theories, 2nd Edition
Boston: Davis & Co 2005 ISBN : 0-8036-1194-3


Fothergill N, Hashemi K.  1990
A prospective study of assault victims attending a suburban A&E department. Arch Emerg Med 1990 ; 7 : 172-7


Gazmararian J A, Adams M, Saltzman L E, Johnson C H, Bruce F C, Marks J S, et al for PRAMS working group. 1995
The relationship between pregnancy intendedness and physical violence in mothers of newborns.
Obstet Gynecol 1995 ; 85 : 1031-8


Gazmararian J A, Lazorick S, Spitz A M, et al.  1996
Prevalence of violence against pregnant women.
JAMA 1996 ; 275 : 1915-20


Gelles R J.  1988
Violence and pregnancy : Are pregnant women at greater risk?
J Marriage Fam 1988 ; 50 : 841-7.


Gerbert B, Abercrombie P, Caspers N, Love C, Bronstone A.  1999
How healthcare providers help battered women: the survivors' perspective. Women Health. 1999 ; 29 : 115-135


Hague G, Malos E. 1998
Domestic violence: action for change. 2nd ed.
Cheltenham: New Clarion Press, 1998.


Hek G. Langton H. Blunden G. 2000
Systematically searching and reviewing literature.
Nurse Researcher 7 (3) : 40-57.


Hewison, A. 2004
Management for Nurses and Health Professionals: Theory into practice. Blackwell Science : Oxford. 2004


Hilberman E, Munson K. 1978
Sixty battered women.
Victimology: Int J 1978 ; 2 : 460-70.


Howe and  Anderson  2003
Involving patients in medical education
BMJ, Aug 2003 ; 327 : 326 - 328.


Hudson W  W, McIntosh S R.  1981
The assessment of spouse abuse: 2 quantifiable dimensions.
J Marriage Fam 1981 ; 43 : 873-88.


Humphreys C, Thiara R. 2002
Routes to safety: protection issues facing abused women and children and the role of outreach services.
Bristol: Women's Aid Federation of England, 2002.


Kyriacou D N, Anglin D, Taliaferro E, et al.  1999
Risk factors for injury to women from domestic violence.
N Engl J Med 1999 ; 341 : 1892-8.


Macnee C L 2004
Understanding Nursing Research. Reading and Using Research in Practice. Philadelphia, Lipincott Williams and Wilkins 2004


Marks-Moran & Rose  1996
Reconstructing Nursing: Beyond Art and Science
London: Balliere Tindall October, 1996


Mcleod M.  1984
Women against men: an examination of domestic violence based on analysis of official data and national victimization data.
Justice Quarterly 1984 : 170-93


McGrath M E, Hogan J W, Peipert J F. 1998
A prevalence survey of abuse and screening for abuse in urgent care patients. Obstet Gynaecol 1998 ; 91 : 511-14.


Meleis A. 1991
Theoretical thinking: development and progress. 2nd edition.
Philadelphia : Lippincott Company, 1991.


Mezey G C, Bewley S 1997
Domestic violence and pregnancy
BMJ 1997 ; 314 : 1295  (3 May)


Mirrlees-Black C.  1999
Domestic violence: findings from a new British crime survey self completion questionnaire.
London : Home Office Publications, 1999:1-136


Mohammed, D Braunholtz, and T P Hofer   2003
The measurement of active errors: methodological issues
Qual. Saf. Health Care, Dec 2003 ; 12 : 8 - 12.


Mooney J.  1993
The hidden figure: domestic violence in north London — the findings of a survey conducted on domestic violence in the north London Borough of Islington. London: London Centre for Criminology, Middlesex University, 1993.


Newell and Simon. 1992
Human Problem Solving.
Prentice-Hall, Englewood Cliffs: 1992.


Newton R R, Connelly C, Landsverk J A. 2001
An examination of measurement characteristics and factoral validity of the Revised Conflict Tactics Scale.
Educ Psychol Meas 2001; 61 : 317-35.


Norton L B, Peipert J F, Zierler S, Lima B, Hume L.  1995
Battering in pregnancy: an assessment of two screening methods.
Obstet Gynecol 1995 ; 85 : 321-5.


Peralta R L, and Michael F. Fleming 2003
Screening for Intimate Partner Violence in a Primary Care Setting: The Validity of "Feeling Safe at Home" and Prevalence Results
J Am Board Fam Pract, Nov 2003 ; 16 : 525 - 532.


Piantadosi S. 1997
Clinical Trials: A Methodologic Perspective.
New York: John Wiley, 1997.


Prochaska J O, DiClemente C C, Norcross J C. I 1992
In search of how people change: applications to addictive behaviours.
Am Psychol. 1992 ; 47 : 1102-1114.


Prochaska J O, Velicer W F, Rossi J S, et al.  1994
Stages of change and decisional balance for 12 problem behaviours.
Health Psychol. 1994 ; 13 : 39-46.


Ramsey J, Richardson J, Carter Y H, Davidson L, Feder G.  2002
Should health professionals screen women for domestic violence? Systematic review.
BMJ 2002 ; 325 : 314.


Rees C 2003
Introduction to Research for Midwives. 2nd, ed.
Hale : Books for Midwives Press 2003


Roberts G L, O’Toole B I, Raphael B, et al.  1996
Prevalence study of domestic violence victims in an emergency department.
Ann Emerg Med 1996 ; 27 : 747-53.


Spedding R L, McWilliams M, McNicholl B P, et al.  1999
Markers for domestic violence in women.
J Accid Emerg Med 1999 ; 16 : 400-2.


Staquet M J, Hays R D, Fayers P M. 1998
Quality of life assessment in clinical trials: methods and practice, 1st edn.
Oxford: Oxford University Press, 1998.


Stewart D E.  1994
Incidence of postpartum abuse in women with a history of abuse during pregnancy.
CMAJ. 1994 ; 151 : 1601-1604.


Taket A, Jo Nurse, Katrina Smith, Judy Watson, Judy Shakespeare, Vicky Lavis, Katie Cosgrove, Kate Mulley, and Gene Feder 2003
Routinely asking women about domestic violence in health settings
BMJ, Sep 2003 ; 327 : 673 - 676 ;


Tham S W, Ford T J, Wilkinson D G.  1995
A survey of domestic violence and other forms of abuse.
Journal of Mental Health 1995 ; 4 : 317-21.


Vickers, A. J. & Altman, D. G. (2001)
Analysing controlled trials with baseline and follow up measurements.
BMJ, 323, 1123-1124


Wadman M C, Muelleman R L.  1999
Domestic violence homicides: ED use before victimization.
Am J Emerg Med 1999 ; 17 : 689-91


Webster J, Chandler J, Battistutta D.  1996
Pregnancy outcomes and health care use—effects of abuse.
Am J Obstet Gynecol 1996 ; 174 : 760-7.


WHO 1996
World Health Organisation. Global consultation on violence and health: world report on violence and health.
Geneva : WHO, 1996.


Wiist W H, McFarlane J.  1999
The effectiveness of an abuse assessment protocol in public health prenatal clinics.
Am J Public Health. 1999 ; 89 : 1217-1221.


Wright J, Kariya A.  1997
Characteristics of female victims of assault attending a Scottish accident and emergency department.
J Accid Emerg Med 1997 ; 14 : 375-8


Yura H, Walsh M. 1998
The nursing process. Assessing, planning, implementing, evaluating. 5th edition. Norwalk, CT : Appleton & Lange, 1998.


Zink T, Nancy Elder, Jeff Jacobson, and Brenda Klostermann 2004
Medical Management of Intimate Partner Violence Considering the Stages of Change: Precontemplation and Contemplation
Ann. Fam. Med, May 2004 ; 2 : 231 - 239.

Source: Essay UK - http://www.essay.uk.com/free-essays/medicine/domestic-violence-midwives.php



About this resource

This Medicine essay was submitted to us by a student in order to help you with your studies.


Search our content:


  • Download this page
  • Print this page
  • Search again

  • Word count:

    This page has approximately words.


    Share:


    Cite:

    If you use part of this page in your own work, you need to provide a citation, as follows:

    Essay UK, The midwives role in domestic violence | Nursing. Available from: <https://www.essay.uk.com/free-essays/medicine/domestic-violence-midwives.php> [21-07-19].


    More information:

    If you are the original author of this content and no longer wish to have it published on our website then please click on the link below to request removal: