Violence in PregnancyViolence in Pregnancy IntroductionIntroduction

Goals:Goals:

Identify women/ mothers at riskIdentify women/ mothers at risk Screening practicesScreening practices Referral and Safety PlanningReferral and Safety Planning

Did you know pregnant women have a higher risk of Did you know pregnant women have a higher risk of experiencing violence during pregnancy than they experiencing violence during pregnancy than they do of experiencing problems such as pre – do of experiencing problems such as pre – eclampsia, placenta previa or gestational diabetes? eclampsia, placenta previa or gestational diabetes?

Health Canada, 1999Health Canada, 1999

StatisticsStatistics

Incidence of reported violence in pregnancy is Incidence of reported violence in pregnancy is 4 – 17%4 – 17%

Reported DV Cases – 40% of the women said Reported DV Cases – 40% of the women said that violence began during pregnancythat violence began during pregnancy

1 in 6 women report the first abuse occurred 1 in 6 women report the first abuse occurred during pregnancyduring pregnancy

Women abused during pregnancy were 4 times Women abused during pregnancy were 4 times as likely as other abused women to say they as likely as other abused women to say they experienced very serious violence such as experienced very serious violence such as beating, choking, gun/knife threats and sexual beating, choking, gun/knife threats and sexual assaultassault

CDCCDC

56% of abused women are between 18 and 34 56% of abused women are between 18 and 34 years of ageyears of age

21% of women in Canada who reported abuse 21% of women in Canada who reported abuse by an intimate partner said they were abused by an intimate partner said they were abused during pregnancyduring pregnancy

IPV Guidelines, British Columbia Reproductive Care IPV Guidelines, British Columbia Reproductive Care Program, 2003Program, 2003

95% of women abused in the first trimester 95% of women abused in the first trimester were also abused in a three month period were also abused in a three month period after deliveryafter delivery

Health Canada, 1999Health Canada, 1999

Warning Signs in Pregnant Warning Signs in Pregnant WomenWomen

Delayed pre-natal careDelayed pre-natal care Reluctance or refusal to attend pre-natal Reluctance or refusal to attend pre-natal

educationeducation Unexplained bruising – particularly of the Unexplained bruising – particularly of the

breasts and abdomenbreasts and abdomen Continued use or addiction to substances Continued use or addiction to substances

such as cigarettes, drugs and/or alcoholsuch as cigarettes, drugs and/or alcohol Recurring or unexplained psychosomatic Recurring or unexplained psychosomatic

illnesses illnesses History of physical illnessHistory of physical illness

Identifying Women at RiskIdentifying Women at Risk

3 Methods (in a medical setting)3 Methods (in a medical setting) Chart reviewsChart reviews> Injuries consistent with assault> Injuries consistent with assault Multiple medical visitsMultiple medical visits History of drug use, depression or suicide attemptsHistory of drug use, depression or suicide attempts Eating disordersEating disorders Unexplained somatic symptoms including choking Unexplained somatic symptoms including choking

sensationsensation Obstetrical/ gynecological history i.e. spontaneous Obstetrical/ gynecological history i.e. spontaneous

or elective abortions, STIs, preterm labour or or elective abortions, STIs, preterm labour or bleeding, low birth weight, unexplained fetal bleeding, low birth weight, unexplained fetal injuries present at birth, unexplained intrauterine injuries present at birth, unexplained intrauterine fetal demisefetal demise

Direct Questioning/ Direct Questioning/ ScreeningScreening

““With so many women experiencing abuse during With so many women experiencing abuse during pregnancy, screening for abuse during pregnancy pregnancy, screening for abuse during pregnancy must be must be a routine part of prenatal carea routine part of prenatal care”. ”.

Health Canada, 1999Health Canada, 1999 Recommendation that woman abuse be a topic Recommendation that woman abuse be a topic

included on standard formsincluded on standard forms BORN – BORN – Better Outcome Registry Network – Better Outcome Registry Network –

question on data base regarding woman abusequestion on data base regarding woman abuse Paper commissioned by College of Family Paper commissioned by College of Family

Physicians of Canada’s Maternity and Newborn Physicians of Canada’s Maternity and Newborn Care Committee – (January 2000)Care Committee – (January 2000)

““All pregnant women should be screened”. All pregnant women should be screened”.

Screening for AbuseScreening for Abuse

Purpose Purpose

1.1. To identify any abuse experienced by the To identify any abuse experienced by the woman in the past or in the present.woman in the past or in the present.

2.2. Decrease the incidence and prevalence of Decrease the incidence and prevalence of woman abuse by identifying abuse as a health woman abuse by identifying abuse as a health issue and responding appropriately with issue and responding appropriately with effective treatment, documentation and effective treatment, documentation and referrals.referrals.

Research has shown that indicator – based Research has shown that indicator – based identification for woman abuse is not as effective identification for woman abuse is not as effective or consistent in achieving early identification and or consistent in achieving early identification and interventionintervention

Routine universal comprehensive approach avoids Routine universal comprehensive approach avoids stigmatization of abused women. stigmatization of abused women.

RUCS ProtocolRUCS Protocol

Routine ScreeningRoutine Screening- Done on a regular basis- Done on a regular basis- Whether or not indicators of abuse are - Whether or not indicators of abuse are

present. present.

Universal ScreeningUniversal Screening

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

Comprehensive ScreeningComprehensive Screening

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

Guiding Principles for Guiding Principles for ScreeningScreening

A – ATTITUDE A – ATTITUDE and and APPROACHABILITY APPROACHABILITY of the of the health care professional;health care professional;

B – BELIEF B – BELIEF in the woman’s account of her own in the woman’s account of her own experience of abuseexperience of abuse

C- CONFIDENTIALITY C- CONFIDENTIALITY is essential for disclosure;is essential for disclosure;D – DOCUMENTATIOND – DOCUMENTATION that is consistent and that is consistent and

legible;legible;E – EDUCATION E – EDUCATION about the serious health effects of about the serious health effects of

abuse; and abuse; and R – RESPECT R – RESPECT for the integrity and authority of each for the integrity and authority of each

woman’s life choices and woman’s life choices and RECOGNITION RECOGNITION that the that the process of dealing with the identified abuse must be process of dealing with the identified abuse must be done at her pace, directed by her decisions. done at her pace, directed by her decisions.

Stigma of “happy family”Stigma of “happy family” Health care professionals, family Health care professionals, family

and friends may not be open to and friends may not be open to disclosure disclosure

““Rooming In”Rooming In” Pressure and expectations re. labour Pressure and expectations re. labour

and delivery, breastfeedingand delivery, breastfeeding

BarriersBarriers

Health ImpactHealth Impact

Abdominal Trauma - Fetal fractures, rupture of Abdominal Trauma - Fetal fractures, rupture of the uterus, liver or spleen the uterus, liver or spleen

Studies show that the attacks are usually Studies show that the attacks are usually targeted at the breasts, abdomen and genitals targeted at the breasts, abdomen and genitals

Maternal morbidity and mortalityMaternal morbidity and mortality

Increased risk of miscarriage, low birth weight, Increased risk of miscarriage, low birth weight, fetal injury and/or fetal death fetal injury and/or fetal death

Other ComplicationsOther Complications

Uterine ProlapseUterine Prolapse Antepartum HemorrhageAntepartum Hemorrhage Premature rupture of membranesPremature rupture of membranes Premature labourPremature labour Abruptio PlacentaAbruptio Placenta Vaginal InfectionVaginal Infection Increased 1Increased 1stst and 2 and 2ndnd trimester bleeding trimester bleeding HeadacheHeadache Irritable Bowel SyndromeIrritable Bowel Syndrome Chronic Pelvic PainChronic Pelvic Pain Increased risk of Sexually Transmitted Illnesses Increased risk of Sexually Transmitted Illnesses

or HIV/AIDSor HIV/AIDS

Dynamics of DVDynamics of DV

PrenatalPrenatal Abuser may control access to careAbuser may control access to care Concern with partner being overly solicitous, Concern with partner being overly solicitous,

prevents her from seeing the professional in prevents her from seeing the professional in private, does not allow her to answer questions private, does not allow her to answer questions herselfherself

Prenatal classes – abuser may embarrass her, Prenatal classes – abuser may embarrass her, may be rough with the woman, more concerned may be rough with the woman, more concerned about what other think than the woman’s about what other think than the woman’s comfortcomfort

Ridicule and teasing, calling her names such as Ridicule and teasing, calling her names such as “cow” or “blimp” “cow” or “blimp”

Demanding to know sex of the babyDemanding to know sex of the baby

In LabourIn Labour Abuser controls decisions regarding epidural, Abuser controls decisions regarding epidural,

pain medication or other interventionspain medication or other interventions Disparaging comments regarding her body, Disparaging comments regarding her body,

and the baby’s sexand the baby’s sex Demanding repair/restore the vagina to pre – Demanding repair/restore the vagina to pre –

birth statebirth state Refuses to leave her aloneRefuses to leave her alone Complaining about how “all this” affects himComplaining about how “all this” affects him

After the birthAfter the birth The abuse may increase and the baby is used as a The abuse may increase and the baby is used as a

weapon, he may deny accessweapon, he may deny access Failure to support, sulking, complainingFailure to support, sulking, complaining Demanding sexDemanding sex Negative comments about appearanceNegative comments about appearance Blame if the baby is “the wrong sex”Blame if the baby is “the wrong sex” Put down her parenting abilityPut down her parenting ability Threaten to or abduct the babyThreaten to or abduct the baby Make her stay home, prevent her from taking a jobMake her stay home, prevent her from taking a job Make or threaten child abuse allegationsMake or threaten child abuse allegations Withhold money for suppliesWithhold money for supplies

Role of Health Care Role of Health Care ProvidersProviders

Be educated about domestic violenceBe educated about domestic violence UnderstandUnderstand

- her reluctance to disclose due to shame, - her reluctance to disclose due to shame, embarrassment, housing and financial issuesembarrassment, housing and financial issues

- she may hope the pregnancy will reform an abusive - she may hope the pregnancy will reform an abusive partnerpartner

- the pregnancy may be a form of abuse i.e. sexual - the pregnancy may be a form of abuse i.e. sexual assault, marital rape, contraception forbiddenassault, marital rape, contraception forbidden

- unintended or unwanted pregnancy – the - unintended or unwanted pregnancy – the woman is 4 times more likely to experience abusewoman is 4 times more likely to experience abuse

- the pregnancy may be a form of control/ coercion, - the pregnancy may be a form of control/ coercion, the abuser’s way to commit the woman to the relationshipthe abuser’s way to commit the woman to the relationship

Ask about abuseAsk about abuse Assess immediate riskAssess immediate risk Assist the woman to develop a safety Assist the woman to develop a safety

planplan Make referrals to available Make referrals to available

resourcesresources Follow-upFollow-up

Follow upFollow up

Women who received, in an empowering Women who received, in an empowering manner, a nursing intervention designed to manner, a nursing intervention designed to provide them with information on the cycle of provide them with information on the cycle of violence, a danger assessment, information on violence, a danger assessment, information on the options available to them, safety planning, the options available to them, safety planning, and resource referrals… and resource referrals…

Lower incidence of physical and non physical Lower incidence of physical and non physical abuse at six and twelve months after abuse at six and twelve months after interventionintervention

Used significantly more safety behaviourUsed significantly more safety behaviourParker et al. 1999. Parker et al. 1999.