Domestic violence and pregnancyBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7090.1295 (Published 03 May 1997) Cite this as: BMJ 1997;314:1295
Risk is greatest after delivery
- a Section of Forensic Psychiatry, St George's Hospital Medical School, London SW17 ORE
- b Department of Obstetrics and Gynaecology, St Thomas's and Guy's Hospitals Trust, London SE1 7EH
Domestic violence is reported by up to one in four women in Britain1 and represents a serious public health issue. The psychological and social consequences of domestic violence include alcohol and drug dependence, suicide attempts, depression, and post-traumatic stress disorder.2 3 Pregnancy may increase the risk of violence,4 5 6 7 and the pattern of assault may alter, with pregnant women being more likely to have multiple sites of injury and to be struck on the abdomen.4 5 6 7 However, the risk of moderate to severe violence appears to be greatest in the postpartum period.8
Several studies have found that women attending accident and emergency departments with physical injuries due to domestic violence are more likely to be pregnant than women attending with accidental injuries.4 In contrast, one study reported that pregnancy led to a decrease in domestic violence, with the result that the women may try to protect themselves by repeatedly getting pregnant.6 Women may additionally be subjected to sexual abuse and assault,9 raising the possibility that conception itself occurs as a result of rape. Victims of domestic violence seem significantly more likely to describe their pregnancy as unplanned and unwanted than women without such experiences.10
Between 11% and 41% of antenatal attenders in American studies report a history of domestic violence at some point in the past, and between 4% and 17% report domestic violence during the current pregnancy.2 5 11 12 Estimates of prevalence vary according to the screening method used, the number of times the woman is questioned, and whether she is asked on repeated occasions.8 13 The use of structured screening questions by staff significantly improves detection rates in a clinical population.12 13
The risks of domestic violence are particularly acute in pregnancy, where the health and safety of two potential victims are placed in jeopardy. Domestic violence is associated with increased rates of miscarriage, premature birth,14 low birth weight, chorioamnionitis, fetal injury, and fetal death.4 6 7 15 Increased drug and alcohol use, smoking, and suicide attempts in battered women are all potentially injurious to the developing fetus.5 12 15 The fetus may be indirectly harmed by women being prevented from seeking or receiving proper antenatal or postpartum medical care by their violent partners.10 12 Physical injuries to live fetuses include broken bones, stab wounds, and fetal death. Once the child is born, battered women are more likely to report child abuse or to fear it.4
Pregnant women are not routinely screened for the presence of domestic violence by health professionals, although standard inquiries are made about other risk factors. Paradoxically, recent changes in midwifery and obstetric practice designed to “empower” women and demedicalise childbirth may have reduced the possibility of effective intervention. The traditional refuge of woman-only space in antenatal wards and labour wards is disappearing. The milieu of the antenatal clinic is not particularly conducive to facilitating disclosure of domestic violence, which women find difficult, shameful, and risky. Men often accompany their partners to clinics and in labour, and hand held notes mean that confidential documentation is no longer in the safe keeping of the hospital.
Women may need protection from violence and intimidation by their partners, and it is important that there are provisions to accommodate this need. 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. More research is required on interventions that might reduce the risk of violence and offer women protection. Insensitive or judgmental responses by health professionals can easily compound the woman's sense of isolation and helplessness. Women are particularly vulnerable to domestic violence during pregnancy and the neonatal period. Rather than ignoring the issue, midwives, general practitioners, and obstetricians must develop clinical practices that recognise the risk and enhance the safety of women and their unborn children.