Issue date: 19 April 2004

ISSUE DATE: 19/04/04

More instances of domestic violence would be disclosed if midwives were trained to ask appropriate questions of pregnant women, according to a detailed year-long study just completed in Bristol. The study found that with proper training and effective multi-agency working the initial involvement of midwives could lead to improved services in the areas of maternal health, domestic violence and child protection.

During the project seventy-nine community midwives in
the North Bristol NHS Trust – representing almost all of those working in the Trust’s community area - underwent specialist training days. The training and research was carried out by the University of the West of England’s Health and Social Care Faculty in collaboration with the Trust, and was funded by the Department of Health.

The effectiveness of the training was assessed after six months and levels of disclosure were assessed at nine months during implementation. Post- implementation, input was sought from key stakeholders including a range of higher education institutions. Researchers also produced a website and teaching pack and are developing a video that could be used on a national basis to train student and post-registration midwives in dealing with these issues.

“Domestic violence in pregnancy is a major public health issue with serious consequences for maternal and infant health,” said Debra Salmon, project manager from UWE who led the research.

“Earlier work on the subject shows that around 25% of domestic violence starts during pregnancy – and women may also experience an increase in the extent and nature of physical abuse at this time. Domestic violence is a key issue in maternal deaths, but our review of previous studies showed that women rarely voluntarily disclose their abusive experiences to health professionals (NICE, 2001). Our results suggest that after the training, midwives had increased confidence in dealing with the issue and this increased the number of opportunities for women to disclose abuse.”

A majority of women are in favour of routine questioning if asked by a well-trained health professional. For midwives, however, there were considerable challenges in making effective antenatal enquiries.

“Midwives felt that they needed more education and support on the topic,” said Ann Remmers, Director of Midwifery at the Trust. “Statistics showed that when routine enquiry was voluntary, only 10% of midwives chose to include questions on this topic in their clinical practice.”

In 2000, the Department of Health endorsed routine antenatal enquiry for domestic violence: this was also endorsed by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, and NICE who in 2001 recommended that all pregnant women should be asked routinely about domestic violence as part of their social history.

“Before introducing this on a national basis, however, it was vital to find out the level and types of education and ongoing support needed to enable a routine enquiry service to be successful – and that is where our research came in,” continued Debra.

“Our recommendations include the need for effective inter-agency working, so that when disclosure of domestic violence occurs, the appropriate support is there and referrals can be made. We also recommend an inter-professional approach to training be developed within both pre- and post-registration midwifery education. Ideally, central funding is required to support the local recruitment of specialist midwives to provide expert education and ongoing guidance around family violence and its links to child protection.

“We also point out the implications for record-keeping – this must be clear but not place a woman at risk - and the need for translation and specialist services for women for whom English is not their first language. Key to success is the opportunity for women to speak to health-care professionals without their partner being present.”


Editor’s notes

1. Full name of the study is An impact evaluation of the Bristol Pregnancy and Domestic violence Programme to promote the introduction of routine antenatal enquiry for domestic violence at North Bristol NHS Trust by Debra Salmon, Kathleen Baird, Sally Price and Simon Murphy, 2004, Faculty of Health and Social Care, University of the West of England.
2. The training video and teaching pack, entitled “Domestic violence and pregnancy: how to ask the question” will be launched in mid-May 2004.
3. The report will be presented to the UK Public Health Association conference - Sustaining Public Health in a Changing World: Vision to Action, 19-22 April. Under Secretary of State for Public Health Melanie Johnson is due to attend 20th April.
4. Previous research studies include:
- Helton, A. McFarlane, A. Anderson, E. (1987) Battered and pregnant: a prevalence study. American Journal of Public Health 77 (10) 1337 - 9
- Andrews, B. and Brown, GW. (1988) Marital violence in the community: a biographical approach. British Journal of Psychiatry 153 p305-312
- Royal College of Midwives. (1997) Domestic abuse in pregnancy. Position paper 19. London: Royal College of Midwives.
- Department of Health (2000) Domestic violence: a resource manual for health professional London: Department of Health
- National Institute for Clinical Excellence, The Scottish Executive Health Department and the Department of Health Social Services and Public Safety: Northern Ireland (2001) The Confidential Enquires into Maternal Deaths in the United Kingdom. Why Mothers Die 1997 – 99 London: RCOG
- Johnson, JK. Haider, F. Ellis, K. Hay, DM. and Lindow, SW. (2003) The prevalence of domestic violence in pregnant women. British Journal of Obstetrics and Gynaecology Vol 110 p272 - 275

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