msc in child forensic studies gl
TRANSCRIPT
1
Geraldine Linke
MSc in Child Forensic Studies:
Psychology and Law
2
MSc in Child Forensic Studies: Psychology
and Law
Table of Contents
Acknowledgements Page 4
Declaration
Page 5
Abstract Page 6
Introduction Page 7
Historical perspective Domestic Violence
Page 9
Depth of Understanding
Page 10
Conflicted Emotions
Page 11
Child Protection
Page 11
Centre for Maternal & Child Death Enquiries
Page 12
Intuition Page
13
Psychological Paralyses
Page 14
Domestic Violence in Perspective
Page 15
Purpose & Rationale for Study
Page 15
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Aims
Page 16
Methodology & Design
Page 16 Participants
Page 16
Procedure
Page 17
Ethics Page
18
Data Analysis Page
18
Results and Discussion
Page 19
Overall summary & conclusion
Page 26
References
Page 28
Acknowledgements:
I would like to thank my supervisor Dr Julie Cherryman for
all her encouragement, support and eternal optimism. I
would like to thank all the Midwives who gave their
precious time and commitment for the study. In particular
a thank you is extended to Tricia Bratby and Gill Slade
who was always willing to ‘read’ my story. Thank you also
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to Sian who transcribed all interviews, a long and difficult
task, you did a fantastic job.
I would especially like to thank my lovely husband Harvey
for his encouragement, patience, advice and importantly
technical support throughout my course; I am deeply
appreciative of you being there. My three sons Elliot,
Daniel and Ciaran, who are now great cooks, know how to
use a washing machine and without whom life would have
no joy.
In memory of Helen Hutchinson, an inspiring
Midwife and friend.
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Declaration:
I declare that the research described in this report is
purely my own work, and the report is an original
manuscript. All data used in the investigation was
personally collected and was done so following the
specified methodology. In accordance with the University’s
policies, my project has undergone and passed all the
necessary ethical approvals. I declare that such ethical
approval was obtained by the Department of Psychology
prior to the conduct of the project.
I declare that my word count is
8235 words
September 13th 2013
6
Domestic Abuse and Pregnant Women: Who
Cares?
What is the role of the Midwife?
Abstract
Violence against women is a national and global concern, (Devries,
Watts, Yoshihama, Kiss, Schraiber, Deyessa, & Garcia-Moreno,
2011). It is estimated that one in every four women will face some
form of violence in their lifetime (World Health Organization, 2005).
Pregnancy can act as a trigger for Domestic Violence (Home Office
Definition, Appendix 6) and abuse or exacerbate an existing
problem; this has serious consequences for maternal and infant
health and may lead to potential morbidity and mortality
(Kavanaugh, & Miller, 2012). Subsequently, Midwives are expected
to ask pregnant women by routine confidential enquiry (RCE) about
Domestic Violence (DV), yet many do not. The importance of
understanding this reluctance should not be underestimated as not
one life is at stake, but two. This study explores the perceptions,
experiences and attitudes of Midwives asking woman about DV. Five
Hospital and five Community Midwives were recruited via
opportunity sampling. These midwives were individually interviewed
using semi-structured interviews which were audio recorded and
transcribed verbatim. From the analysis of the data, three main
interrelated themes were discussed: Environment, the task of asking
the question depended on the setting the Midwives worked in.
Consequences, which meant the Midwives acknowledged both their
clinical responsibilities and the physical safety of the mother and
baby; despite the conflicting emotional issues involved. Lastly,
experiences, as it was found that Midwives experienced extreme
reactions when asking about DV. Although they expressed desire to
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offer support, it was unclear which external resources they could
call upon. The implication of this study concerns the whole
maternity environment. Arguably, there is a need for mandatory DV
training involving an awareness of available resources and regular
reflective supervision with psychological support.
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Introduction
It is estimated that one in every four women will face some form of
violence in their lifetime (World Health Organization, 2005). As
pregnancy can act as a trigger for Domestic Abuse or exacerbate an
existing problem, the effects of violence against a pregnant woman
can have serious consequences for maternal and infant health,
leading to potential morbidity and mortality (Baird, Salmon & White,
2013). The care of pregnant victims of violence is significant to all
agencies (Williston & Lafreniere,
2013), as it is not only one life which is at stake, but two. Healths
practitioners are primarily clinicians working from a ‘health’
perspective subsequently the forensic medical responses to
domestic violence have - for the most part - been negligible (Nittis,
Hughes, Gray, & Ashton, 2013). This has led to lost opportunities
and a failure to address, document or attribute any causation of
injuries to a perpetrator; this leads to potential evidence not
meeting the standards required by court. Although it has
traditionally been considered the duty of the Police and courts to
respond to domestic
and sexual violence, relatively few women report violence to the
criminal justice system (Women’s National Coalition, 2009). Whilst it
is recognised that women in abusive relationships can be fearful of
disclosing their abuse, Midwives are often the first healthcare
professional a woman will talk to, if asked, in addition Bostock,
Plumton, Pratt (2009) highlight the fact that women do not object to
being asked the question, preferring to have the opportunity to be
asked. In the UK, Domestic Abuse has shifted from being ‘behind
closed doors’, into the public arena and is now firmly established as
an important public policy issue (Peckover, 2013). Midwifery policy
reflects this as Midwives are expected to ask about DV, making a
‘Routine Confidential Enquiry’ (RCE). However, some do not feel
confident to do so (Salmon Murphy Baird & Price, 2006). Chaplin,
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Flatley and Smith (2011), reported in 2010/11 (British Crime
Statistics) that there were 392,000 incidents of Domestic Violence
and this is - due to under-reporting - presumed to be a low estimate.
Despite such figures, Taylor, Bradbury-Jones, Kroll, & Duncan,
(2013) found some Health Practitioners did not share the same
beliefs about screening for DV, preferring not to open a Pandora’s
Box (Henderson, 2001). Understanding such beliefs, reluctance or
lack of confidence in asking the question about DV should not be
underestimated. The rationale for asking about DV is that an
intervention may happen early enough to ‘break the cycle’ and
prevent inter-generational abuse, by signposting the expectant
mother to the relevant agencies such as Women’s Aid; for practical
support and often much needed legal advice. This study aims to
explore the ‘real world’ views of local Midwives about their
experiences and attitudes towards DV to seek a deeper
understanding of the potential difficulties faced.
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Historical background of Domestic Violence
Domestic violence in pregnancy is not a new phenomenon (Bailey &
Giese, 2013). Three great bodies of thought have influenced
Western society’s views and treatment of women: Judeo-Christian
religious ideas (Fox, 2013), Greek philosophy (Brown, 2013) and the
Common Law legal code (Brundage, 2000). All of these derive from
the basis of male supremacy and have led to patriarchal societies.
There is a long heritage of Domestic Violence being seen as a
‘private affair.’ 19th Century courts document numerous cases of
pregnant women being beaten even when in labour (Wojtczak,
2009). The Victorian attitude was one of resignation, there appeared
little a woman could do to stop violent attacks and only the
prosecution of a man for extreme violence was acknowledged. Law
enforcement at the time also dealt with Domestic Violence in a
dismissive and derogatory way (Curran, 2010). It was not seen to be
in the ‘public interest’ and the police did not wish to intervene
(Truninger, 1971). Such attitudes contributed to and mitigated the
violence by ‘playing down’ its significance.
‘It’s just a domestic’ Curran (2010)
Society would still prefer to think of Domestic Violence as an issue
that affects only the lower, uneducated classes (Aaltonen, Kivivuori,
Martikainen & Salmi, 2012). However, in the 21st Century it is well
documented that Domestic Violence knows no boundaries of class,
colour, or religious persuasion (Khalifeh, Hargreaves, Howard &
Birdthistle, 2013). Pizzey, an early social campaigner of the 1970’s
argued that there is ‘indifference, red tape, callousness and simple
incompetence’ between those that needed help and the agencies
that might provide such help. This was seen as detrimental to both
women and children (Pizzey, 1974, p91). It has taken decades of
campaigning and government lobbying to highlight the damaging
effects DV has on women, children and family life (Harvie & Manzi,
2011 & Weldon & Htun, 2013). The Domestic Violence, Crime and
Victims Act 2004 created the biggest overhaul of the law on
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domestic violence in the last 30 years. The Act made significant
changes to the way in which instances of domestic violence are
dealt with by the courts, together with other measures such as
multi-agency risk assessment committees (MARAC) which were
created to improve the treatment of victims and witnesses of
domestic crime. In an effort for agencies to work and learn together,
multi-agency domestic homicide reviews have been established to
analyse deaths which are a result from violence by a relative, or
within an intimate personal relationship.
In addition to changes in the Law, and in determination to address
this sensitive issue at an early stage, the Royal College of Midwives
have issued practice guidelines to their staff, as statistics show that
Midwives are uncovering DV at much lower rates than estimates in
the literature (Mezy Bacchus Haworth & Bewley, 2003). Lazenbatt
Thompson-Cree & McMurray (2005) reported that Midwives were
reluctant to enquire about DV as doing so created tensions between
their clinical role and what could be perceived as surveillance.
Whilst professional awareness has increased over the years, it
appears that the same barriers exist which prevent Midwives from
asking (Lazenbatt Thompson-Cree & McMurray 2005, Mezy Bacchus
Haworth & Bewley, 2003), even when these factors are mitigated
for, such as a training programme to enhance confidence levels or
the time to attend (Aldridge, 2013).
This study aims to explore if such attitudes are consistent with
previous findings.
Depth of Understanding
As Domestic Violence has shifted from being ‘unknown’ to ‘known’
(Stanley, Miller, Richardson Foster, and Thomson, 2010) the scale of
DV incidents appears overwhelming with thousands reported
annually in Buckinghamshire alone. Due to the volume, agencies
(Police and Social Care) have to ‘triage’ the reports to be able to
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deal with them. The risk of this is that many ‘minor’ incidents are
not actioned which has the potential effect of minimising or even
normalising it. Perhaps Midwives believe that they alone are
expected to tease out the elements of risk, dangerousness and
resilience of a woman (Peckover, 2013) to provide protection for the
mother and unborn child. However, referral rates from Midwives to
multi-agency risk assessment committees (MARACs) are very low.
On completion of the Domestic Abuse Stalking and Harassment form
(DASH), all women that have been risk assessed as ‘high’ are
discussed (Richards, Letchford and Stratton, 2008). However, there
is a shortage of Midwives nationally and case-loads are high (Price,
2012). The MARAC process can also take time and perhaps the
enormity of the task and of their case-loads prevents Midwives from
enquiring about DV in the first place. As identification of Domestic
Abuse increases, it raises the question as to whether the
categorisation of ‘it’s just a domestic’ will once again be the default
position for busy professionals operating in overstretched services
(Peckover, 2013). This issue will be investigated in this study.
Conflicted Emotions
The prevalence of domestic violence means it is likely that Midwives
will encounter women who have experienced abuse at some stage
in the course of their work and need to be adequately prepared. 15
years ago, Scobie & McGuire (1999), recognised the impact of DV on
pregnant women and highlighted the Midwives’ lack of confidence
when enquiring about DV. Midwives felt ill prepared due to lack of
training and feared that they did not know how to support a woman
if she did disclose abuse within a relationship. In addition, they were
unclear of how and when they would broach the subject, especially
when women attended appointments with partners or other family
members. Changes in attitudes amongst Midwives can be perceived
as moving slowly. According to Goldblatt (2009), working with
abused women can have detrimental emotional cognitive and
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behavioural influences on practitioners such as transference of high
anxiety (Neumann, & Strack, 2000) and low emotion resulting in
vicarious traumatisation. The resulting effect was to not look or
screen for Domestic Abuse; for whilst Practitioners felt empathy and
compassion, they also felt anger and confusion. The analysis of the
data in this study will be mindful of this issue.
Child Protection
Although pregnancy is no protection from violence, (Zanville, &
Cattaneo, 2012) many pregnant women stay with their partners as a
means of preventing the escalation of violence caused by
attempting to leave (Enander, 2010). Yet, it would be expected that
both the Midwife and Mother see the protection of the unborn as a
priority that could be the catalyst for change. Engnes, Lidén &
Lundgren (2012) described the women in their study as needing
help in order to make the changes, yet they felt embarrassed and
ashamed to find themselves in such situations. The same feelings
were expressed by Midwives in early studies when discussing DV
(Johnson, Haider, Ellis, Hay, & Lindow 2003) and (Mezey, Bacchus
Haworth & Bewley 2003). However Engnes, Lidén & Lundgren
(2012) suggested that professionals had to overcome such feelings
in order to prioritise the unborn infants’ safety, whilst preserving the
mother/Midwife relationship. For those women who have
experienced intense levels of coercive control from partners
(Williamson 2010), speaking about DV takes courage as many have
few supportive networks to rely on and struggle to control the
situation (Edin, Dahlgren, Lalos & Högberg, 2010). They may see the
Midwife as their only means of advocacy, whilst at the same time
fearing that the consequences of disclosure will result in referrals to
Child Protection agencies.
The lived experience for many women experiencing Domestic Abuse
is fear. This can be seen from at least three perspectives: fear of
what a partner may do if the disclosure becomes known to them,
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fear from ‘authority’ figures and the fear of being seen as an ‘unfit’
Mother and even having the baby removed from their care following
delivery (Crittenden, Farnfield, Landini, & Grey, 2013). Domestic
abuse also has strong associations with child abuse which can affect
the infants’ physical and emotional health, their learning and their
capacity to form positive relationships throughout their lives
(Lazenbatt, 2012). Flaherty, Sege, & Hurley, (2009) suggested infant
maltreatment is one of the most serious events undermining
healthy psychological well-being and development. No other social
risk factor has a stronger association with developmental
psychopathology. Given the serious consequences of this social
phenomena, it is surprising that the research viewed (Lazenbatt,
Thompson-Cree, & McMurray, 2005 Crawford, Liebling-Kalifani, &
Hill, 2013) suggested a reluctance by Midwives to ask about DV. The
rationale for this study is to examine why this might be the case.
The Centre for Maternal and Child Death Enquiries
In modern society, pregnant women are encouraged to speak to
their unborn from the moment of conception; getting to ‘know’ and
‘connect’ with them is part of the transition into motherhood
(Levendosky, 2013) and is seen as the foundation of a strong and
secure attachment (Levendosky, Lannert & Yalch, 2012). Bowlby
(1980) recognised that the explanation for much human behaviour
has its basis in the mother-infant interaction. Specifically, more
avoidant or anxious individuals are less likely to express affection
and deal with conflicts (Gay, Harding, Jackson, Burns & Baker,
2013). Dutton & White (2012) further suggested that any set of
psychological factors that have anxiety or fear as a component
affect the status quo of the relationship, leading to an inability to
resolve areas of conflict without resorting to verbal or physical
aggression. It would seem counter-intuitive to stay with a violent
partner, thus exposing the baby to harm (Bell, & Naugle, 2006).
Further, Theobald & Farrington (2012) suggested the long term
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impact of this ‘highly charged’ environment for the baby impacts
hugely on an individual’s emotional and developmental trajectory
for later life transitions. This would seem especially poignant in light
of the fact that the Domestic Violence definition has been extended
by the Home Office to include girls from 16 years old, who under the
definition of the Children Act 1989 are still ‘children’ themselves.
Motz reports that a basic understanding of attachment models and
disturbed attachment styles can be helpful; as abetter
understanding could help to inform about the relationship difficulties
some women face (Motz,2010, p342). The Centre for Maternal and
Child Enquiries (2011) (CMACE) highlighted that during 2006-2008,
Domestic Violence featured in the deaths of 34 women, for 11 of
those women the abuse was fatal and the direct cause of death. An
intervention by a Midwife may ‘break the cycle’ of intergenerational
abusive and damaging relationships (Lapierre, 2010). This study
focuses on the perceived attitudes of Midwives and may highlight
any attitudinal changes from previous studies.
Intuition
In real life situations, problems present themselves in ways that
may or may not be ‘picked up’ by Midwives, or indeed any
Healthcare Professional. Husso, Virkki, Notko, Holma, Laitila &
Mäntysaari (2012) described problem situations as ones that are
puzzling, worrying or something you cannot ‘put your finger on’. In
nursing, the use of intuition was hotly contested (Lyneham,
Parkinson, & Denholm, 2008) and was not seen as the basis for
sound clinical decision making. However, to dismiss intuition as
invalid is to underestimate the fact that intuition is based on a
combination of experience and knowledge through explicit learning
and clinical practice (Witteman, Spaanjaars, & Aarts, 2012). Whilst
Midwives may have an ‘inkling’ about something, reluctance to
intervene may result from a fear of ‘getting it wrong’. In addition,
fear of offending has previously been cited as a reason for not
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asking the question. Ethical decision making is complex. Although
guided by the Nursing and Midwifery Council (2002), Varcoe, Doane,
Pauly, Storch, Mahoney, McPherson, Brown, Starzomski (2004)
suggested nurses working with their own values could have
competing interests with their organisations. Any action or inaction
seen in the clients’ ‘best interests’ has to be carefully considered
(Walker, Kershaw & Moon, 2009), as the stark reality is that two
women are killed each week at the hands of their partners or ex
partners (Richards, Letchford, and Stratton 2008). For pregnant
women an early intervention from a Midwife may prevent such a
tragedy.
Psychological Paralyses
Taylor, et al (2013) expressed surprise to find that some health
professionals believed the women themselves played a part in or
contributed to the DV. Perhaps this should not come as a surprise.
Health Professionals such as Midwives and Nurses are
predominately female and domestic violence is predominantly
gender based (Anderson, 2013). Women have often found
themselves blamed for staying in violent relationships, especially
where children are involved (Enander, 2010). Society places women
at the ‘heart’ of the home and central to its overall function
(Nicholas, 2013). Leaving the home takes considerable courage and
comes with a high personal and emotional cost. Victims may be said
to have a ‘psychological paralysis’ (Hayes, & Jeffries, 2013) which
prevents them from action, increasing a sense of ‘the futility of it
all’. Such psychological paralysis may also be reflected in the beliefs
of the Midwives in that the ‘emotion’ of dealing with DV increases
their sense of the futility of intervening, especially if they believe
that the women will go back to their abusive partners. Perhaps then
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organisations are not paying enough attention to the affect that
working with Domestic Violence has on practitioners. Expecting staff
to effectively differentiate between their home and professional
lives is unrealistic without putting something more than ‘training’ in
place. While many practitioners may not recognise ‘burnout’ in
themselves, Coetzee, & Klopper (2010) recognised it as a state of
mind that progresses from a state of: compassion discomfort, to
compassion stress and finally to compassion fatigue; which if not
effaced in its early stages can permanently alter the compassionate
ability of the nurse. This presents a significant challenge to
organisations, as the psychological wellbeing of staff is seen as
critical for an effective work force (Haslam, Jetten, Postmes &
Haslam, 2009). The question of adequate support will be addressed
within the study.
Domestic Violence in Perspective
However front-line practitioners perceive Domestic Violence this
issue is firmly on the Maternity strategic agenda as the safety of not
one but two individuals are placed at risk (Price, Baird, & Salmon
2007). To offer a perspective, in Obstetric care worldwide the
prevalence of pre-eclampsia ranges from 3 to 8% of all pregnancies
(Anderson, Olsson, Kristensen, Akerstr¨om & Hansson 2012).
Whereas, the findings of the Multi-Country Study on Women's Health
and Domestic Violence against Women show average prevalence
rates between 30% and 60% (García-Moreno, Jansen, Ellsberg,
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Heise, & Watts, 2005). It would be considered clinically negligent to
ignore or discharge a pregnant woman with pre-eclampsia, yet
women experiencing Domestic Violence can find themselves in this
position. Griffiths (2102) informs that civil law allows women, usually
in the form of compensation, to seek redress if they believe that
harm has been caused through a Midwife's clinical carelessness.
However, there is no evidence to suggest that this course of action
is applied when discharging a woman back to a violent situation.
There appears to be support and guidance from the government
(DoH, 2005) and an expectation from the local NHS Trusts that
Midwives will ask this question. However, the fact remains that this
is not an easy task and Midwives as well as many other health
professionals, face real challenges in responding safely and
effectively to the increased pressure to identify women in abusive
relationships (Lazenbatt, Thompson-Cree, & McMurray, 2005).
Purpose and Rationale for this study
In the UK, Domestic Abuse has shifted from ‘behind closed doors’
into the public arena. It is now firmly established as an important
public issue and this is reflected in national maternity policy
(Peckover, 2013). Midwives are often the first healthcare
professional a woman will disclose to about Domestic Abuse, if
asked. The relevance and significance of Midwives routinely asking
about DV, is linked directly to the adverse and even fatal foetal and
maternal outcomes of violence perpetrated against the expectant
mother. Intervening could provide an opportunity to prevent such
adverse outcomes, yet Midwives demonstrate reluctance in
initiating such questions routinely. Understanding such reluctance is
crucial if the long term patterns of abuse are to be reduced. I was
previously involved in the Homicide review of a young local mother
of two very small children and I believe that hindsight can usually
provide us with some learning. I was struck by the findings as for me
this case highlighted the lack of information sharing between Health
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Practitioners. In addition, the mother was not asked RCE directly by
any health practitioner during her two very recent pregnancies. This
was seen as a lost opportunity, (Storer, Lindhorst, & Starr, 2013).
Aims of this study
The findings from the Homicide Review prompted the rationale for
this study which sought to gain an understanding of the Midwives’
attitude to asking about DV. This study differs from other studies in
that it is not looking at the effect of training to increase the
regularity or consistency in which questions are asked. The study
aims to draw on the experience of asking about DV in real life
situations and to explore any subsequent effects.
Methodology
Design & Materials
Based on the literature previously discussed and my personal
experience of participating in a Homicide Review, for this qualitative
study I designed a semi-structured questionnaire to facilitate and
investigate the research question. A poster (appendix 1) was
prepared and widely circulated within all maternity settings,
covering both Hospital and Community bases approximately 8
weeks before the study began. The poster outlined the aims of the
study and the confidential nature of the interviews conducted. A
Dictaphone was used for recording purposes and the subsequent
recordings were stored securely on a private PC.
Participants
Broad participation was encouraged by opening the study to all
Midwives across the whole Trust. This included: ward, clinic and
community settings. The final sample consisted of five Hospital and
five Community Midwives, therefore 10 individual semi-structured
interviews were conducted. The participants were all qualified
registered Midwives with a range of experiences and qualifications
20
from 3 years to 31 years post qualification. Two Midwives were part-
time and five were full time. Three did not comment. One
participant divided her time between the Community and the
Hospital, but at the time of interview she was working in the
Hospital and was coded as a Hospital Midwife. All the Midwives were
female as there are no male Midwives currently working within this
Trust.
Procedure
I conducted ‘drop in’ sessions in both Hospital and Community
settings. At first, the Midwives were recruited randomly if they were
available and willing to complete the interview at the time.
However, the take up was poor and conducting the research this
way resulted in several failed attempts to meet with interested
Midwives; particularly Hospital based Midwives who are dependent
on shift patterns and do not have the same time flexibility as
Community Midwives. I wanted to include Midwives from all areas of
practice in order to gain as much information as possible from as
wide an audience as possible. To enable participation, I made myself
available at the beginning and end of shifts at handover time; this
took several attempts but did increase the chances of a Hospital
based Midwife being available and willing to interview. The
interview, using the semi-structured questionnaire, took place on
Trust property during normal working hours. Each Midwife was seen
in a private room within the maternity building. The purpose of the
research and the consent form were explained and both the
participating Midwife and I signed the informed consent form
(appendix 2). The question of anonymity was discussed and
participants were assured that the information would be safely and
securely stored. Participant identification would not be disclosed to
anyone other than the researcher and the University supervisor. The
participants were advised that they could withdraw from the study
up to 2 weeks following the interview; although none of them did.
21
The interviews were 20-35 minutes long and each was audio
recorded using a small Dictaphone. Each audio tape was transcribed
by an assistant and stored securely on a private PC. As this research
is based on a sensitive subject, which has become more prevalent,
(appendix 3 debrief). I sought the advice of a senior Midwife and
occupational health adviser should any of the Midwives have
required it. However, none expressed the desire to discuss any
issues following
completion of the interview. In fact, given the opportunity to talk
about it, some Midwives expressed great interest in the topic and
found it ‘thought provoking’. A vast, rich and colourful account of
Midwives perceptions and attitudes was given freely by all the
Midwives. After each interview, a verbatim account was then
transcribed by an assistant. The transcriptions were then checked
for accuracy against the original recordings which I listened to
numerous times. The semi-structured interview was chosen to allow
the participants a level of freedom to respond to the subject topic.
The opening question being ‘How useful do you feel it is to ask
women about Domestic Violence?’ I coded the responses to identify
any strong features of the interviews. With this, I endeavoured to
ensure that as many codes as possible were identified that were
representative of the Midwives experiences and not based on any
presumptions I may have had prior to the study. I am aware that
having additional coders may enhance the ‘trustworthiness’ of the
data (White, Oelke, & Friesen, 2012).
Ethics
The Department of Psychology’s ethics committee approved this
research as
consistent with the British Psychological Society’s Code of Conduct.
The confidentiality and anonymity of the participants were of
paramount importance. The data collected included names, whether
they were a Community Midwife (CMW) or a Hospital Midwife
22
(HMW). Each Midwife was assigned a letter (ABCDEFGHIJ) for
anonymity.
Data Analysis
The data was analysed following the six phases outlined by Braun, &
Clarke (2008). Thematic analysis offers a number of advantages,
including clear identification of prominent themes, organisation,
structure and flexibility (Dixon-Woods, Sutton & Shaw, 2007).The
initial phrase involved repeatedly reviewing and listening to the
audio interview transcripts. I made headings from what I considered
salient points although many recurring comments overlapped. In an
attempt to summarise, the main points were placed under a single
heading. From the initial 28 codes (appendix 4) several overlapped,
i.e. audit/paperwork/documentation. Each interview transcript was
cross checked in an effort to develop the themes that appeared
most commonly (appendix 5). Four main themes emerged but
again, there was some overlap. Finally, like the original research
question, three themes emerged. These final three themes were
considered to be of overarching importance to the Midwives,
informing their sense of duty and responsibility for the pregnant
women.
Results and Discussion
The three themes presented from the data are:
Environment
Consequences and
Experience
23
The themes will be discussed in turn with reference to other studies
and with regard to the possible implications for practice and
possible further research.
Environment:
It appears that the environment in which the question about DV is
raised is important to the Midwives interviewed. Differences were
observed between the frequency in which Hospital Midwives and
Community Midwives described their difficulty with asking questions
based in various settings. In clinic settings, some Midwives have
very limited contact with pregnant women. These Midwives may
have a different perception towards the importance or relevance of
asking women questions about
Domestic Abuse; particularly when other more clinical/medical
matters are competing for their immediate attention. This held true
even when the clinic in question dealt mainly with high risk
pregnancies.
‘Our managers tell us we have to ask this question. I physically
cannot do it. When it is a particularly quite clinic, there are more
opportunities to do it but on a normal clinic, I just don’t get around
to asking the question,’ HMW2/B
‘We are aware of its importance because of the media and of course
pregnancy exacerbates this situation. It is a very awkward question
to ask a stranger. The community Midwife may also be in this
situation; however they are often not in such a clinical environment
and have a more general line of enquiry within the booking history,’
HMW 2/B
Both Hospital and Community Midwives report that Community
Midwives have more of an opportunity at the booking appointment
to ask any number of questions, both medical and social. Certainly,
all five Community Midwives expressed that they were not afraid to
be frank. ‘ I have always approached it the same way, relaxed, calm,
routine, so they don’t feel they are being targeted’ HMW1/A
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One Midwife was very matter of fact: 'I ask the question as if I was
asking to take their temperature. Using the same tone of
voice..............when you ask some of the girls whether they have
ever taken drugs they casually answer Cannabis, Es (Ecstasy)
Cocaine. They are quite honest about it, we never used to hear
anything about that but then we never asked' HMW1/A
Another: ‘I really try to do a booking at home, the women feel more
comfortable and are more likely to answer your questions in their
own safe environment.’ CMW2/G
Two Hospital Midwives reported feeling unwilling to ask someone
they hardly know such a question, particularly if they are coming
into the ward in labour as this could be seen as inappropriate.
Perhaps this is not surprising; it would be difficult to imagine that
either the Midwife or the labouring woman would see this as a
priority over the safety of the Mother and baby. However, one
Hospital Midwife did believe that there was more of an opportunity
when the woman was in Hospital because the men ‘have to go
home at some stage’ HMW1/A. Community Midwives reported
asking in broad terms and did not report having had negative
response from women, although one Midwife reported that one lady
recently said to her: ‘Well, what you do if I said yes?’ The Midwife
went on the explain what she could offer and signpost the Mother to
other agencies that could offer more practical help, the women
denied experiencing domestic abuse but she let the Midwife talk on.
This informs us of the need to have current up to date local
information readily available. There was a sense that Hospital-based
Midwives were in at the 'sharp end'. The difficulties of dealing with
the stressful event of labour and an argumentative couple were
expressed by one Midwife, who recalled a situation,' ‘on the delivery
suit, because they were arguing, talking to her like she was deaf…
we could all hear him……he was stressing everyone……..I told him
I’d call security if he didn’t calm………….he did……….it’s her I feel
sorry for, who needs that when you’re in labour?’ HMW4/D
25
This excerpt graphically illustrating the difficulties Midwives and
women face when an already potentially stressful situation gets out
of control. The Midwife clearly expresses sympathy for the labouring
woman and irritation with the partner.
An experienced midwife lamenting on the change in working
practice as not so many home visits are now carried out. The quote
demonstrates a number of changes, both from the general public
and midwifery profession. ‘Oh yes. I don’t think we even thought
about the questions then, it was never mentioned in our training or
practice. I don’t think I was overly aware of the women’s situations. I
worked on the labour ward and so only got a small snapshot of their
situation. I think then, the public were better behaved in that
situation. There wouldn’t be so many clues about their situation if
you hadn’t visited their home. Back then, we did a lot more home
visits and so the patient was more comfortable about the idea of
you visiting their home, it was very accepted’HMW3/C
Consequences
This theme explores the consequences for both the women and of
the Midwife asking the question. ‘At the moment there seems to be
a number of women I have referred or would like to refer but social
services have done an assessment and don’t think they need to be
seen.’ HMW3/C Midwives play a pivotal role in the care of pregnant
women and may be one of the first Healthcare Practitioners that a
woman will disclose to about DV, if asked. The Midwives are in a
unique position as people who can help and influence a woman to
disclose information, if they perceive the external support to be
effective. The consequences of violence to the pregnant mother are
serious and can be fatal. An intervention by means of signposting to
other agencies may ‘break the cycle’ of the abusive relationship. As
one midwife relayed: I don’t’ know. Would she have told me if I
hadn’t asked, probably not’ CMW1/F This study confirmed the
Midwives awareness of the physical safety of the Mother and unborn
26
child and is in line with other studies. Nine Midwives expressed
concern of the risks of DV for the baby and one midwife highlighted
the risk of maternal homicide. In line with other studies (Taylor et al,
2013) (Lazenbatt Thompson-Cree & McMurray, 2005), the midwives
expressed incomprehension as to why some women appear to make
the ‘choice’ to stay with abusive partners. This could be indicative of
midwives having only a basic or superficial understanding of DV, as
some believed the women themselves contributed to the DV.
Attribution is something we all do every day, usually without any
awareness of the underlying processes and biases that lead to our
inferences (Storer, Lindhorst, & Starr, 2013). Old attitudes to DV are
still influential and perhaps Midwives – like everyone else - attribute
blame, because they believe the victim should somehow be able to
predict, or at least prevent abuse by simply walking away. Women
find themselves blamed for staying in violent relationships,
especially where children are involved (Enander, 2010). Particularly
when Midwives believe they have tried to help the women flee the
situation only to find she has returned to her partner.
‘Another lady who already had 4 children and was expecting her
5th, which she didn’t want because of Domestic Violence. I felt very
sorry for her and we really tried to help her (me and the Health
Visitor) but again she stayed with him’ CMW4/I
‘I would speak to my manager here, more to talk to somebody, to
clarify the situation and see if I am on the right path. Then I would
be inclined to have a chat with the woman herself and say that I
have concerns about her and if I felt that there was a problem the
concern would be for the unborn baby. The mother may have
chosen to remain in a certain situation; the baby doesn’t have this
choice. CMW2/G
Pregnancy is no protection from violence so many women make
complex choices (Zanville, & Cattaneo, 2012). The reasons for
staying or leaving a partner are multi-faceted; sometimes they stay
as a means of preventing the risk of escalation caused by
27
attempting to leave (Enander, 2010). This study demonstrated the
emotional impact of working with clients who may be classified as
‘high risk’ but who may not recognise abuse in their relationship, or
minimize the effects of it on themselves, their unborn or their
children. The consequences of DV are varied and women do not
present with one set of symptoms or injuries, such varied
presentations can make it difficult to assess. For Midwives, this may
be a particularly important and difficult dichotomy in that they have
clinical responsibility for two lives.
‘It did impact on my thoughts, its all well and good asking the
question …..but it’s what happens in the end I suppose……………it
was her home, money, stigma…..she said going to a refuge left her
and the children with nothing ….. for all of them,…………he was a
good father in many ways, ……….the drink affects him’ CMW4/I
One Midwife was clear what she thought of violent men:
‘Banish men who batter women’ CMW2/G
‘Yes, when I asked an Asian lady she disclosed to me at booking that
her husband had hit her once. When I asked her how she felt now,
she felt that it wasn’t a problem and that he knew that if it
happened again he would be out CMW2/G. The Midwife said she was
impressed by her. The Midwives were aware of the consequences of
managerial and peer scrutiny of the Maternity records. Five
Midwives described difficulty with documentation. ‘On another point
there is serious violence where babies are victims themselves. We
had a recent case of a baby taken to A&E with shaken baby
syndrome and then I don’t think we had the notes where we could
actually document that we had asked the question.’CMW4/I
Although they reported being well supported by managers, poor
performance in documentation of RCE could be seen as a
disciplinary matter, as policy and procedure now indicate this has to
be completed. Five Midwives discussed writing this in the records. It
would be disappointing if an organisation threatened disciplinary
action; more important is the role that supervision plays in
28
supporting the midwives emotionally with this type of work. Not one
of the midwives talked about supervision in a formal way, although
they did talk about the support they received from specialist Midwife
for Child Protection/Managers and peer support.
Experience of asking
This theme arises from the complexities faced by both women and
Midwives of asking the question. It can be seen from a practical
training perspective and from a personal resilience perspective.
Quite a lot of women will joke about it and make light of the
question CMW3/H Midwives have a vague ‘working’ knowledge of
the potential effectiveness of MARAC. Until DV & MARAC training
becomes mandatory for health practitioners, the safety and welfare
of pregnant women remains at risk as practitioners will fail to
recognise abusive behaviour. For example, it is important to
understand that domestic violence stalkers (often ex-partners), are
more likely to be violent than any other type of stalker. Additionally
if they make a threat, 1 in 2 of them will act on it (McEwan, Mullen,
McKenzie & Ogloff, 2009). Efforts to improve safety are seen as a
priority for the criminal justice system (CPS, 2013) and the Health
Service must also send a powerful message that violence against
women and girls will not be tolerated. Midwives were confident in
their clinical role and expertise; they did not see themselves taking
on other roles as they were aware of their limitations and perhaps of
others: ‘We are trained Midwives, not Social Workers’ CMW3/H
‘Many of the roles, Health Visitor, School Nurse didn’t come in to
their roles thinking they would be so involved with safeguarding
children’.HMW3/C ‘It makes me feel quite responsible, that I need to
do something to make sure they are safe. It is a lot
easier if they do want to leave and are willing to do something
about it. You can have a situation where they don’t want to do
anything about it. I have got one at the moment who went to the
police because her partner tried to strangle her. She has
29
subsequently dropped the charges and is now denying it all, but
obviously she disclosed it, then it's difficult, you have to ask is she
safe? Is the baby safe you think if they don't know what do to how
are we supposed too? CMW3/H
The experience of being exposed to potentially violent relationships
was captured by one CMW: 'You have to be non-judgemental. Often,
we do get upset, one of our midwives received some horrible texts
from a patient, really abusive because she had been the one to ask
the question'. Asking the question may not always elicit the
response you were expecting. As one Midwife described, when
asking the woman about DV she explained that her own mother had
been abusive to her. Midwives have to be prepared to offer some
level of emotional support in situations like this.
Particularly when as professionals, we should be aware of the long
term consequences of abusive relationships.
‘Yes, I have found from experience that I have probably had X
women disclose and all of those women have received help, even
one who actually went to Child Protection and her husband went to
court and eventually she did have him back.’ CMW4/I
‘I did have one girl who was a victim and when I went to book her,
he was at work and she burst into tears and said he had started
hitting her and she wanted to have an abortion and tell him she had
had a miscarriage. She did leave him in the end. She was an English
Asian girl living with his family. I gave her the information about
abortion because that is what she wanted. I have seen her since and
she is fine.’ HMW1/A
Such excerpts are informative, as Midwives should be aware that
these women's lives are not just divided into two parts, the pre-
leaving part and the post-leaving part. The experience of living with
DV stays with them. As Crawford, Liebling-Kalifani, & Hill, (2013)
suggest, they remain wary of reprisals from ex-partners, living with
the fear that 'services' will intervene and concern at their ability to
cope.
30
‘People have gone through things in their relationships… you can’t
tell what they’ve been through’ CMW2/B
One Midwife expressed shock at the experience of one 25 week
pregnant women describing to the Midwife her journey through an
Accident and Emergency department. The explanation of a fall down
the stairs was immediately accepted as truthful and not questioned.
It was not until she was admitted to the labour ward, that the
subject of DV was approached and the expectant Mother said she
had been pushed. This narrative highlights that the clinical
presentation in some areas (A&E) takes priority and ‘follow on’
questions about how the injury happened are not always asked
(Basu & Ratcliffe, 2013). Given the prevalence of DV, this is a
curious finding, although it is recognised that obtaining an accurate
understanding of injury to DV victims is difficult, as there is not a
standardized method of describing or defining how injuries occur
(Sheridan, & Nash, 2007). That said, as victims of violent assault
seeking help will usually attend an A&E, staff should be able to
recognise and advise patients on possible avenues of support as
well as treating their physical injuries.
This study supports the findings of Goldblatt (2009) by suggesting
that the Midwives’ encounters with abused women illustrate a range
of reactions. Not just about the women’s stories, but also the role
that other professionals may play in the overall care of the pregnant
woman.
‘In A&E they didn’t ask……….. and she didn’t tell…………’ CMW
Intuition plays a part in this study also. There is evidence to suggest
that using ‘intuition’ can change
outcomes for patients and certainly Midwives in this study
expressed it well,
‘I think your instincts tell you to escalate things……even when she
says it’s her fault……..you can call the police if you feel it’s
dangerous,’ HMW1/A
31
‘it was useful for her, she was truthful, she didn’t really understand
it just felt he was suffocating her lifestyle while being lovely and
supportive…… we both knew what was happening, but you can’t
mind read and could get it wrong……but if you do where’s the harm,
if they are OK they’ll so say’. CMW5/J
‘I knew something wasn’t right, but I didn’t know why. She was 5
days post caesarean section and he had even sent her to Asda to
collect the photographs. She shouldn’t even have been driving. He
didn’t want to risk me being there with her when he was out. I
remember being quite uncomfortable about ‘it.’ HMW1/A
During the interviews Midwives demonstrated an acute awareness
of Domestic Violence and the implications for pregnant women.
Bacchus, et al (2002) and Lazenbatt, et al (2005) suggest that
Health Professionals are too slow to respond to the growing
evidence that women welcome the opportunity to be asked about
DV and that fear of offending or embarrassment should not stand in
the way.
‘I have always approached it in the same way, very relaxed, calm
and routine, so they don’t feel they are being targeted. One woman
said “well sort of” and when I asked her what she meant, she said
“he pushed me around a bit”. I did explain to her that research
shows these things can escalate during pregnancy and advised her
to keep an eye on things. I gave her the numbers and said we could
talk about it later. HMW1/A
Yet Midwives in this small sample expressed creative ways and
means of asking the question, aware of taking perhaps the only
opportunity there was to ask. Six Midwives spoke of ‘lying and
making excuses’ to get the women alone as they were acutely
aware of need for confidentiality and safety. Attitudes have
changed. This is in line with Baird, Salmon & White (2013) who
reported positive changes in attitude in the five years since their
original research to asking the question.
32
‘Yes, we are a lot more aware. There isn’t such a stigma and they
are looked on as the victims. We know they are psychologically
down-trodden’. HMW1/A
‘If you can never get a chance to ask the woman properly and you
can see that every time you see her she is accompanied, you know
there just was no opportunity to ask any questions. Sometimes this
kind of behaviour, along with other suspicions can give you a clue
that something is wrong. I don’t think it is harmful [to ask] in any
way’.HMW3/C
However, this can take time as one midwife said reflecting on her
experience whilst working in the Community; ‘it took me 8 months
to get the women on her own…….I did eventually during a home
visit when he was at work………in her case it was OK, but I felt
better for asking’. HMW1/A
For this Midwife, having an unanswered question about Domestic
Violence was like ‘unfinished business’. The Midwife did not feel her
work was complete until this task had been done. This demonstrates
the impact of DV on professionals and this evidence should not be
over looked or minimized. Six of the Midwives expressed the
importance of support from senior managers and felt they were
supported by their immediate colleagues and line managers.
Overall Summary & Conclusion
This study sought to explore the ‘lived’ experiences, perceptions
and attitudes of Midwives to asking pregnant women about
Domestic Violence. NHS Trust initiatives and Government responses
to Domestic Abuse have placed this firmly on the Maternity agenda
and Midwives are now expected to routinely ask women about it.
However, this small scale study suggests some ambiguity towards
asking the question. Midwives have a clinical responsibility for the
safe delivery of mother and baby. Therefore, dealing with DV
extends this clinical responsibility and requires the Midwife to put
aside any ‘personal’ thoughts and feelings about asking aside.
33
Whilst they did not wish to be judgemental, many of the Midwives
had the experience of supporting the women only to find they had
returned to the relationship. The sense of futility involved in
intervening may impact on levels of empathy and compassion. The
data demonstrated the seriousness in which Midwives saw their role
coupled with the ‘raw’ sense of the complex and difficult world
experienced by some of the women they worked with. That said,
Midwives would also benefit from mandatory training as they
appeared to lack a real understanding of the role that MARACs
played in assessing and managing risk for women, or the role they
could play by referring such vulnerable women. Being actively
involved in a multi-agency approach to supporting the victim may in
turn increase a sense, for the midwife, that everything that can be
done is being done. Such narratives provide important and
sometimes overlooked information about the personal effect on the
Midwives in relation to their professional lives. The trust as an
organisation faces real challenges if it is to support staff, particularly
psychologically, with the impact of working in difficult and
emotionally demanding situations. This only serves to highlight the
importance of formal reflective clinical supervision that can inform
clinical practice and contain practitioners. The study also highlighted
some environmental differences to asking the question and was
dependent on the clinical area the Midwives were working in. This
was an unexpected variance, where clinical priorities outweighed
social ones. Perhaps this should not be so surprising when the
clinical safe delivery of mother and baby must take priority. The
issue of asking the question in variable settings may benefit from
further research as there was a sense that hospital Midwives felt
‘pressurised’ to ask and worried about possible disciplinary action if
they failed to do so.
This study addressed the initial aims of the research question;
however it appears that ‘asking the question’ is a complex and
34
difficult responsibility, with many factors influencing Midwives in
their decision to complete this task. Midwives are aware of their
unique position in identifying DV and need regular on-going training
and reflective supervision in order to achieve the goals set both
nationally and locally.
35
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