Midwives' and obstetricians' perception of their role in the identification and management of family violence.
Focus groups and semi-structured interviews with midwives and obstetricians were conducted, recorded and analysed.
Identification themes included concerns about privacy and confidentiality, the doctors' lack of continuity of patient care, and the role of screening. Management themes included uncertainty regarding management and referral options, the impact of managing family violence on clinicians, and the need for debriefing.
Maternity health professionals in the locale studied have significant issues and difficulties in the identification and management of family violence. These need to be addressed in training programmes and guidelines to improve patient outcomes, and to provide support and safety for clinicians. Further research is required to achieve saturation of themes and explore identified issues, which can then be used to focus on interventions. Keywords: midwife, obstetrician, pregnancy, violence, abuse
Family violence may begin, carry on or worsen during pregnancy. An international review reported a prevalence of 3.9-8.3% (Gazmararian, Lazorick, Spitz, Ballard, Saltzman & Marks, 1996). Family violence is more common than conditions routinely screened for, such as diabetes and hypertension (Janssen, Holt, Sugg, Emanuel, Critchlow & Henderson, 2003). Family violence during
pregnancy is associated with intrauterine growth retardation (Moraes, Amorin & Reichenheim, 2006; Janssen et al, 2003), antepartum haemorrhage and perinatal death (Janssen et al, 2003). Pregnancy provides a window of opportunity for identification of family violence and previous research suggests that asking about family violence is acceptable to most pregnant women (Bacchus, Mezey & Bewley, 2002; Stenson, Saarinen, Heimer & Sidenvall, 2001).
Midwives recognise family violence as an important issue (Mezey, Bacchus, Haworth & Bewley, 2003; Stenson, Sidenwall & Heimer, 2005). The New Zealand College of Midwives (NZCOM) implemented midwifery family violence education in 2002, the same year that the Ministry of Health published FV intervention guidelines (Fanslow, 2002). There is little information on obstetricians' perception of their role in dealing with family violence. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) (2004), have introduced an educational module for Obstetric and Gynaecology trainees, consultants, as well as GPs, on management of adults who have experienced sexual assault.
It is crucial that practitioners feel capable of identifying affected women and providing appropriate care. Currently practitioners are not adequately identifying family violence, and abused women tend not to disclose it (Hegarty & Taft, 2001; Bacchus, Mezey, Bewley & Haworth, 2004). Appropriate training and guidelines are vital, and it is important to include the experience of practitioners working in maternity care in their development. The aim of this exploratory study was to investigate opinions of midwives and obstetricians regarding their role in identification and management of family violence.
Focus groups and semi-structured interviews were used to investigate the perceptions and experiences of maternity practitioners in the identification and management of pregnant women affected by family violence. All 28 midwives and 11 obstetricians working at Dunedin Public Hospital were invited to attend a focus group discussion, one for obstetricians and one for midwives. Small incentives were offered for participation. Five midwives participated in one focus group and two obstetricians in another. Due to the small number of obstetrician participants, obstetricians who did not attend the focus group were invited to individual semi-structured interviews; three obstetricians did so. Midwives were not invited to have an interview as the number of midwife focus group participants was adequate (Brown, 1999).
All focus group and semi-structured interview discussions were conducted by the authors in the Department of Women's and Children's Health, Dunedin Public Hospital, Dunedin, during November 2002. An interview guide was developed from the results of a literature search for prompting and focusing discussion, and participants were encouraged to raise issues they considered important. The obstetrician focus group and semi-structured interviews lasted approximately 30 minutes each, and the midwife focus group lasted approximately 90 minutes. All discussions were audiotaped, transcribed and checked for accuracy by comparing transcripts with tape recordings.
Initial analysis involved independent coding of the transcripts by each investigator, who then met to compare and review their interpretations. Data were organised according to a template coding style. The codes used were broadly categorised as identification or management issues with subcodes as presented in Table 1. Additional categories can emerge and old ones change in this analytical process (Crabtree & Miller, 1999). In this case the template was concordant with the focus group guide areas of enquiry. Findings were combined with consensus into a master file using the software program ATLASTM. There was no automated analysis. Data were connected and corroborated by examining chunks of related text together (Crabtree & Miller, 1999). Ethical approval was granted by the Ethics Committee of the University of Otago, Dunedin, New Zealand.
Midwife participants included two hospital midwives, two independent midwives in community-based practice and one hospital midwife who had also worked independently. The five midwives had an average of 9.8 years in midwifery practice, and all but one reported attending courses about family violence. Obstetrician participants included one hospital based consultant obstetrician and four obstetric registrars. Three were female and two were male. On average the five obstetricians had 9.4 years in obstetric practice and three obstetricians reported no previous education about family violence.
Identification of Issues
Experience in identifying pregnant women who were the victims of family violence ranged from "I don't know that I have seen it" to "lots and all the time". Both obstetricians and midwives acknowledged that identification of these women was "nowhere near as much as it should be" and that their respective professions had a role in the identification of family violence.
The midwives were more experienced in enquiring about family violence, stating "you can't assume anything, you have to ask", whereas an obstetrician made the comment that they "don't go there because it is too difficult". All obstetrician participants perceived midwives as having "a unique opportunity to pick up (FV) ... because they are building a close relationship with the patient,... the trust,... seeing them more frequently".
The midwives agreed, acknowledging that the relationship they developed with pregnant women could help in identifying family violence victims.
"Often women see us as a friend, a mother figure--they confide in you more than they would perhaps with friends or relatives." [Midwife]
Both obstetricians and midwives felt that asking about family violence in a direct fashion was most appropriate.
"I would ask directly because you are not going to get an honest answer unless you are honest, you have to be up front." [Obstetrician]
However obstetricians usually learnt of a woman's experience of family violence secondhand, often from the midwife.
Barriers to Identification
Midwives and obstetricians identified lack of time, perceived complexity of family violence issues, uncertainty about management, and privacy and confidentiality issues as potential barriers to identification.
"It is too emotional to deal with, you don't know how to deal with it..., it's time consuming." [Obstetrician]
Most obstetricians felt that dealing with 'social issues' like family violence were beyond their scope of practice and enquiring about it could feel like intruding. They described identifying family violence as "opening a can of worms" and did not know how to manage it, "not being able to give a pill to make it better."
Midwives and obstetricians perceived privacy as a barrier to identification, including privacy in a clinic setting and diffi culties separating the partner from the pregnant woman. Privacy could be difficult for midwives visiting women in their homes. For obstetricians the lack of continuity of patient care was identified as a barrier. Obstetricians also commented that disclosure only occurred when the women wished to disclose and that these women were often disempowered, in denial and needed to feel in control of any potential disclosure.
"If the woman feels that if she discloses something that isn't going to stay within her bounds of control, then she won't disclose it ... the thing she is fighting against is loss of control." [Obstetrician]
Obstetricians commented that abuse victims will often decide for themselves when to disclose "it's a point that they have to get to themselves" and "was usually precipitated by things like the husband disappearing or a child being badly hurt".
They also stated that "you have to create an environment where disclosure is accepted". This included a good practitioner-patient relationship, continuity of care, adequate time, a confident health professional, privacy and confidentiality. Both obstetricians and midwives discussed the importance of picking up on possible cues, such as a woman's relationship with her partner.
"If a woman has left (her partner) multiple times and returned, that may be one cue ... You see them together..., you get an idea about the tension between the two, or the woman shutting up and the man answering for her." [Obstetrician]
Low self-esteem, history of chronic pain, prior agency involvement and/or a previous history of abuse were also mentioned as cues, as well as physical evidence of abuse. Some obstetricians perceived low socio-economic status, young pregnant women, unplanned pregnancies and drug users as possible risk factors. However other obstetricians and midwives acknowledged family violence is a global issue and could be missed if only particular community groups were considered at risk.
Obstetricians felt that if a screening programme was introduced they needed to know appropriate responses to disclosure. Although they felt they would take part in screening, provided there were definite benefits for the abused women, they perceived midwives as being in a better position to screen successfully. They also felt a suitable environment was essential, particularly ensuring privacy. Midwives felt they had a role in screening pregnant women for family violence, but that the initial booking was not the right time. They also expressed concerns about being adequately trained to deal with disclosure.
"At booking ... they are going to tell you what you want to hear.... It is many visits ... before you actually start to hear things." [Midwife]
Screening could pick up on historic abuse, and midwives wondered if this was appropriate.
Not knowing what to do with information once disclosed, where to refer women, and how to access appropriate services were the most commonly expressed concerns by all participants.
"I am not familiar with what the management plan is ... I am not well armed with like a flow chart ... of who to go to." [Obstetrician]
Midwives and obstetricians described the management of identified abused women as a team approach involving midwives, GPs, social workers and other agencies, and where they relied heavily on advice of others.
Both midwives and obstetricians considered it important not to pressure women as they would be less likely to seek help.
"You need to gain their trust ... Being supportive, listening to what they want to do about it." [Midwife]
However practitioners described frustration when a client would not accept a referral.
"I have got to take ten approaches before a woman would agree to do something about it. I get a bit frustrated with that." [Midwife]
And referral was not always with consent, a potentially difficult situation.
"Explaining that you think their life is in danger, or their children's life is in danger. You promise confidentiality but within certain boundaries ... When they leave (the relationship) is one of the most dangerous times so you can precipitate a problem." [Obstetrician]
Midwives and obstetricians voiced concern about documentation after disclosure of abuse, especially when pregnant women keep their maternity records at home, a common practice in New Zealand.
Barriers to Management
Perceived barriers to successful management of abused women, included inadequate training and limited access to resources. Midwives felt that it was diffi cult for midwifery students to gain practical experience dealing with family violence.
"If you have got a family at risk you are inclined to not take the student down because the dynamics change. If you are trying to build up a relationship with that family, so you can deal with the issues, you don't want a third party there, so they (the student) don't see it." [Midwife]
Facilitators of Management
Obstetricians thought training about resources, referral agencies, communication skills for dealing with disclosure, and medico-legal issues were important.
"Referral options, but also how to deal with disclosure (of FV) ... If you start being angry with them, making them feel worse, making their low self esteem even worse.... It is incredibly important that you get training in it." [Obstetrician]
"the legal side ... when can you intervene? Is it your duty to intervene or are you not responsible for doing something now?" [Obstetrician]
Obstetricians perceived midwives and social workers as invaluable to successful management as they have time, resources and can work beyond the hospital. Midwives felt that having a good knowledge about available referral agencies, their role and accessibility would facilitate management of abused women. Practice guidelines on family violence were helpful though some participants were unsure whether they would result in better outcomes.
"having guidelines and algorithms that show what to do are beneficial. As long as people understand that it is not a rule. This is a guideline to help you, not that you must do this in that situation." [Obstetrician]
Impact on the Practitioner
Midwives described serious boundary issues dealing with victims of family violence.
"I was called at midnight and asked to pick up someone who was standing on the footpath with her suitcases, her three kids and her TV." [Midwife]
"You say, 'All you can do is call the police', and they don't want to do that because in the morning it will be alright. 'He's going to say sorry.... But in the meantime, can you come and get me?... Can you do this? Can you do that?' " [Midwife]
Although the midwives knew it was not their role to intervene in these instances, their genuine concern for women and their children forced them to take action. Midwives could become involved in the power imbalance in an abusive relationship.
"The partners terribly resent your presence sometime. The woman looks to you and the attention is taken away from him. Often you are giving good, positive answers to the woman ... You are boosting up her self esteem and he wants her kept right down where he has got the control so he starts resenting you coming." [Midwife]
Several midwives reported threatening behaviour, both indirectly and directly, towards them from a woman's abusive partner.
"I put myself between the partner and the door ... I made sure I was strategically placed so I could leave the house in a hurry." [Midwife]
"What do you do when that violence gets turned towards you?... I have heard through the woman that they (the abusive partner) are out to get me. ... my husband took me out of town for the day because I was such a nervous wreck that this person was going to find me ... I have also had fairly strong sexual connotations from partners ... That makes you very uncomfortable at times because he is always around." [Midwife]
Being exposed to violent situations could also produce an adverse response.
"As I visited them over the time, that control was horrendous. I wanted to smash his head in." [Midwife]
Obstetricians, however, made no similar comments. In fact, one obstetrician experienced in dealing with family violence, stated that they had never felt at risk when dealing with violent relationships.
"I have felt the danger between them, but have never felt it directed to me." [Obstetrician]
Both obstetricians and midwives expressed the need for debriefing after dealing with challenging cases of family violence.
" It is ... an emotional situation ... I think we are very poor at debriefing ... You need to debrief,... to talk to someone." [Obstetrician]
One obstetrician talked about a mentoring programme with a senior colleague, particularly valuable if the practitioner could choose their own mentor. The midwives had no formal regular peer support but said they "offloaded to each other" and kept a personal journal as a form of reflective practice.
The midwives thought they were in a good position to identify family violence. However many obstetricians felt that family violence was beyond their scope of practice and enquiring about it could feel like intruding. This is concerning when family violence is an internationally recognised health issue and has been associated with poor maternal and fetal outcomes (Moraes et al, 2006; Janssen et al, 2003; Webster, Chandler & Battistutta, 1996).
Lack of time, lack of privacy in clinics and lack of continuity of patient care were perceived as barriers to identification by the obstetricians in this study and midwives in this and previous studies (Bacchus et al, 2002; Mezey et al, 2003). Hospital-based obstetricians usually see patients for a one-off clinic visit, whereas midwives see women regularly, often including home visits, highlighting the different patient-practitioner relationships and opportunities for identification. This may be different for obstetricians practising in the private sector and future studies should include these practitioners. However participant obstetricians were keen to work with midwives in identification and support of women who were victims of abuse.
Both midwives and obstetricians had difficulties supporting disclosure without actively directing the victim of abuse to seek help. General practitioners have described this diffi cult path, dealing with the victims of family violence, as 'walking a tightrope' (Miller & Jaye, 2007). Perceiving particular individuals or groups to be at high risk may mean abused women who are not associated with those groups are more likely to remain unidentified. In a previous study of primary care physicians, 39% stated that they were less likely to consider the possibility of family violence in their differential diagnosis when patients were from a similar social group to themselves (Sugg & Inui, 1992).
Participant midwives felt they had a role in screening for family violence, which is consistent with previous literature (Jones & Bonner, 2002; Bacchus et al, 2002). In the study by Bacchus et al (2002), most pregnant women felt midwives were the most appropriate health professionals to enquire about family violence because of their ongoing and trusting relationship. Obstetricians and midwives in our study agreed. Participant midwives of this study felt the initial booking appointment was not the best time for screening. This was contradictory to previous work where midwives described finding it easier to ask screening questions to new clients (Jones & Bonner, 2002). However Bacchus et al (2002) showed an increased rate of disclosure with advancing pregnancy. This suggests the potential benefits of promoting repeated enquiry about abuse in screening programmes to maximise identification rates.
The documentation issues that concerned participants in this study have been previously described (Taft, 2002). There is a need for alternative forms of documentation whereby a woman's disclosure of abuse can be suitably recorded, without putting her at risk of further violence.
An issue about screening described in this study and seemingly no other, is that family violence screening may identify women's historic abuse. The emphasis of family violence identification has been on current abuse, but identification of historic abuse may also be important and relevant, especially if there are unresolved issues. Furthermore there is an association between family violence and major depression (Leung, Kung, Lam, Leung & Ho, 2002), a risk factor for postnatal depression (Eberhard-Gran, Eskild, Tambs, Samuelsen & Opjordsmoen, 2002). Guidelines and training need to suitably prepare clinicians should current or historic abuse be identified .
Despite participant concerns about screening, recent work has documented the benefits associated with antenatal screening for family violence in obstetric care. In one study screening 159 women, 10.7% disclosed family violence and 23.5% of the women who disclosed, wanted or accepted further assistance from midwives (Jones & Bonner, 2002). However a systematic review of studies on screening for family violence in any healthcare setting concluded that currently there is a lack of evidence of benefit in screening for family violence (Ramsay, Richardson, Carter, Davidson & Feder, 2002).
An important barrier to helping abused pregnant women is that practitioners feel inadequately informed about managing disclosure, where to refer and how to access appropriate services. Midwives and GPs have expressed these concerns in previous studies (Mezey et al, 2003; Miller & Jaye, 2007). The NZCOM has introduced guidelines and training programmes which should improve knowledge, practise, confidence and motivation for midwives dealing with family violence. RANZCOG currently has a teaching module on sexual assault only. Guidelines and training should include information on referral issues and options available, as well as communication skills for dealing with disclosure, and medicolegal issues related to violence and abuse. To be effective, training needs to be ongoing (Protheroe, Green & Spiby, 2004; Berman, Barlow & Koziol-McLain, 2005). Both obstetricians and midwives acknowledged the importance of working with other agencies supporting women who were victims of abuse. The multidisciplinary approach is the cornerstone of practice guidelines and discussed in other studies (Bacchus et al, 2002; Mezey et al, 2003).
Midwives described entanglement in the power imbalance and violence in a woman's abusive relationship. This was consistent with previous reports where midwives expressed fears of being assaulted after screening women for abuse (Mezey et al, 2003). Midwives also described requests from abused women which exceed the boundaries of midwifery practice and may indicate a gap in services for these women. Training should prepare midwives to deal with potential violence and boundary issues. GPs' fear of violent patients, or the patient's partner has been described in other studies (Miller & Jaye, 2007; Brown, Lent & Sas, 1993).
Debriefing after managing emotionally difficult cases was considered beneficial by both midwives and obstetricians in reducing adverse impact. Practitioners need to feel safe and supported in their practice with adequate support networks readily accessible. Practitioner safety and debriefing measures should be included in guidelines, training and practice.
This was a qualitative exploratory study which sampled for information-richness to determine whether issues existed in maternity practice regarding the identification and management of victims of family violence. This study contributes to discussion on this important topic. Its findings were not intended to be generalisable, but do indicate that there are important issues that need to be addressed. This study was limited by small participant numbers, and by using both focus groups and semi-structured interviews in information gathering. However the data obtained from all discussions were meaningful. Small participant numbers could reduce information-richness and some themes may not have been identified. To ensure saturation of themes, further qualitative studies on the role of New Zealand midwives and obstetricians dealing with family violence in both public and private sectors are required. A nationwide survey could then be undertaken. These findings would be very helpful in the development of research on interventions to improve identification and management of family violence in maternity care.
Midwives and obstetricians in the locale studied have concerns about their role in the identification and management of family violence in maternity care. Many of this study's results were consistent with previous literature, but themes such as dealing with historical abuse were documented for the first time. The limitations of this exploratory study do not diminish the significance of the emergent themes. The important issues identified suggest the need for further research on the role of obstetricians and midwives in identification and management of family violence. Research findings should be used in the continuing development of training programmes and guidelines provided by the NZCOM and RANZCOG, to assist maternity practitioners dealing with family violence in a way that is effective and practical rather than just ideal and theoretical, whilst keeping practitioners safe.
The authors are grateful to the Medical Council of New Zealand who funded this research, the participant midwives and obstetricians, and to Dr Chrystal Jaye, Dunedin School of Medicine, for her assistance with the method. Thanks to Roz McKechnie for transcribing audiotapes.
Accepted for Publication: Jan 2008
Lauti, M., Miller, D. (2008) Midwives and obstetrician's perceptions of their role in the identification and management of family violence. New Zealand College of Midwives Journal, 38, 12-16
Bacchus, L., Mezey, G., & Bewley, S. (2002). Women's perceptions and experiences of routine enquiry for domestic violence in a maternity service. British Journal of Obstetrics and Gynecology,109(1),9-16.
Bacchus, L., Mezey, G., Bewley, S., & Haworth, A. (2004). Prevalence of domestic violence when midwives routinely enquire in pregnancy. BJOG, 111, 441-445.
Berman, S., Barlow, K., Koziol-McLain, J. (2005). Family violence prevention education programme for midwives: An Auckland evaluation. New Zealand College of Midwives Journal, 32, 21-26
Brown, J., The use of focus groups in clinical research. (1999). In Crabtree, B.F., Miller, W.L., (Eds.). Doing Qualitative Research. 2nd ed. 109-124. Thousand Oaks: Sage Publications.
Brown, J., Lent, B., & Sas, G. (1993). Identifying and treating wife abuse. Journal of Family Practice,36,185-192. Crabtree, B. F., Miller, W.L. (1999). Using Codes and Code
Manuals. In Crabtree, B.F., Miller, W.L., (Eds.). Doing Qualitative Research. 2nd ed. 163-177. Thousand Oaks: Sage Publications.
Eberhard-Gran, M., Eskild, A., Tambs, K., Samuelsen, S.O., & Opjordsmoen, S.(2002). Depression in postpartum and non-postpartum women: prevalence and risk factors. Acta Psychiatr Scand,106(6), 426-33.
Fanslow, J.(2002). Family Violence Intervention Guidelines. Ministry of Health, Wellington, New Zealand.
Gazmararian, J.A., Lazorick, S., Spitz, A.M., Ballard, T.J., Saltzman, L.E., & Marks, J.S.(1996). Prevalence of violence against pregnant women. JAMA, 275(24), 1915-20. Review. Erratum in: JAMA 1997,277 (14), 1125.
Hegarty, K.L., & Taft, A.J.(2001). Overcoming the barriers to disclosure and inquiry of partner abuse for women attending general practice. Australian and NZ Journal of Public Health,25(5), 433-7.
Janssen, P., Holt, V., Sugg, N., Emanuel, I., Critchlow, C., & Henderson, A.(2003). Intimate partner violence and adverse pregnancy outcomes: a population based study. American Journal of Obstetrics and Gynecology,188(5), 1341-1347.
Jones, C., Bonner, M.(2002). Screening for domestic violence in an antenatal clinic. Australian Journal of Midwifery,15(1),14-20.
Leung, W.C., Kung, F., Lam, J., Leung, T.W., Ho, P.C. (2002). Domestic violence and postnatal depression in a Chinese community. International Journal of Gynaecology and Obstetrics, 79(2), 159-66.
Mezey, G., Bacchus, L., Haworth, A., & Bewley, S. (2003). Midwives' perceptions and experiences of routine enquiry for domestic violence. British Journal of Obstetrics and Gynecology, 110(8), 744-52.
Miller, D., Jaye, C. (2007). GPs' perception of their role in the identification and management of family violence. Family Practice,24(2), 95-101.
Moraes, C., Amorin, A., & Reichenheim, M. (2006) Gestational weight gain differentials in the presence of intimate partner violence. International Journal of Gynaecology and Obstetrics, 95, 254-260.
Protheroe, L., Green, J., & Spiby, H. (2004) An interview study of the impact of domestic violence training on midwives. Midwifery, 20 ,94-103.
Ramsay, J., Richardson, J., Carter, Y.H., Davidson, L.L., Feder, G .(2002). Should health professionals screen women for domestic violence? Systematic review. BMJ,325(7359),314.
Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2004) Medical responses to adults who have experienced sexual assault: an interactive educational module for doctors. Retrieved March 1 2008 from http://www.ranzcog.edu.au/sexual-assault-module.shtml
Stenson, K., Saarinen, H., Heimer, G., & Sidenvall, B. (2001) Women's attitudes to being asked about exposure to violence. Midwifery, 17, 2-10.
Stenson, K., Sidenwall, B., & Heimer, G. (2005) Midwives experience of routine antenatal questioning relating to men's violence against women. Midwifery, 21, 311-321.
Sugg, N.K., & Inui, T. (1992) Primary care physicians' response to domestic violence: opening Pandora's box. JAMA,267(23), 3157-3160.
Taft, A. (2002) Violence against women in pregnancy and after childbirth. Australian Domestic and Family Violence Clearinghouse. (Issues Paper 6), 1-23.
Webster, J., Chandler, J., &Battistutta, D. (1996) Pregnancy outcomes and health care use: effects of abuse. American Journal of Obstetrics and Gynecology,174(2), 760-7.
Dr Mel Lauti MBChB BSc BMedSc
House Surgeon, Dunedin Hospital
Dr Dawn Miller MBChB MRNZCGP PGDipGP
Senior Lecturer in Women's Health
Dunedin School of Medicine
Correspondence to: email@example.com
Table 1. Codes used in content analysis. Identification Previous experience in identification Enquiring about family violence Barriers to identification Factors facilitating identification Screening Management Reflections about current management practice Barriers to management Facilitators of management Impact on the practitioner