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Domestic violence during pregnancy: Midwives׳ experiences
Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Domestic violence during pregnancy: Midwives experiences Elisa Marta Mauri, RM, BMid (Midwife)a, Antonella Nespoli, RM, BMid, MSc (Research Midwife)b, Giuseppina Persico, RM, BMid, MSc, PhD in Physiopathological, Neuropsychobiological Sciences and Life-Cycle Care (Lecturer in Midwifery)b, Virna Franca Zobbi, RM, BMid, MSc, PhD in Nursing and Midwifery Science (Lecturer in Midwifery)b,n a b
John Radcliffe Hospital, OUH, Headley Way, Oxford, OX3 9DU, UK Department of Surgery and Translational Medicine, University of Milano-Bicocca, via Cadore 48, 20900 Monza (MB), Italy
art ic l e i nf o
a b s t r a c t
Article history: Received 11 June 2014 Received in revised form 3 February 2015 Accepted 4 February 2015
Objective: the aim of this qualitative study was to explore midwives' knowledge and clinical experience of domestic violence among pregnant women, with particular emphasis on their perceptions of their professional role. Design: the data collected for this phenomenological-hermeneutical qualitative study were collected using semi-structured interviews, and analysed according to Denzin and Lincoln (2011). Setting and participants: fifteen hospital and community midwives working in the local health district of Monza and Brianza in northern Italy were recruited between July and October 2012. Findings: three main themes emerged: ‘it is difficult to recognise domestic violence’ because of a limited knowledge of the most common signs and symptoms of violence, a lack of training, cultural taboos, and the women's unwillingness to disclose abuse; ‘we have a certain number of means of identifying violence’, such as relationships with the woman, specific professional training and screening tools, which have advantages and disadvantages; ‘the professionals involved’ in identifying and managing family violence highlight the importance of a interdisciplinary approach. Key conclusions and implications for practice: midwives acknowledge their crucial role in identifying and managing domestic violence but are still unprepared to do so and indicate various barriers that need to be overcome. There is a need to implement basic university education on the subject and provide specific professional training. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Domestic violence Intimate partner violence Pregnancy Universal screening Midwives
Introduction Domestic violence during pregnancy Domestic violence during pregnancy is a major public health issue that threatens the health of mothers and foetuses (Janssen et al., 2003; Plichta, 2004; Chambliss, 2008; Sharps et al., 2008; Bailey, 2010; Mikton, 2010). International studies have found differences in the prevalence of domestic violence during pregnancy ranging from 1% to 20% (Jasinski, 2004; Motta et al., 2014), which have been attributed to cultural differences between countries, different definitions of domestic abuse, different means of detecting abuse, and differences in study designs (Edin, 2006; Bailey, 2010). Only a few studies have investigated its prevalence n
Corresponding author. E-mail addresses: [email protected] (E.M. Mauri), [email protected] (A. Nespoli), [email protected] (G. Persico), [email protected] (V.F. Zobbi).
in Italy: Dubini and Curiel (2004) found that 22% of about 300 pregnant women interviewed in some clinics in Florence had experienced violence while pregnant, and a survey published by the National Institute of Statistics' (ISTAT) in 2007 indicated that 11.5% of pregnant women were victims of domestic violence (ISTAT, 2007). Similar rates have been found in Nicaragua, Turkey, Pakistan, Belgium, India, the USA and New Zealand (Bailey, 2010), England (Women's Aid Federation of England, 2012), Canada (Wathen et al., 2003), the Congo, Colombia, Uganda (Devries et al., 2010) and Australia (Phillips and Malcolm, 2006). There is disagreement in the literature as to whether the prevalence of domestic violence decreases during pregnancy, remains about the same, or increases (Bailey, 2010). The 2007 ISTAT survey indicated that violence had begun during pregnancy in 15% of cases, escalated during pregnancy in 16.6%, and remained unchanged in 50.6% (ISTAT, 2007). Pregnancy can therefore trigger or exacerbate violence against women, and may sometimes be the consequence of violence. Pregnant women subjected to domestic abuse are considered at
http://dx.doi.org/10.1016/j.midw.2015.02.002 0266-6138/& 2015 Elsevier Ltd. All rights reserved.
Please cite this article as: Mauri, E.M., et al., Domestic violence during pregnancy: Midwives experiences. Midwifery (2015), http://dx. doi.org/10.1016/j.midw.2015.02.002i
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high risk because exposure to physical, sexual or psychological violence during pregnancy correlates with increased maternal, foetal and infant morbidity and mortality (Janssen et al., 2003; Bacchus et al., 2004; Plichta, 2004; Mezey et al., 2005; Chambliss, 2008; Romito et al., 2008; Sharps et al., 2008; Bailey, 2010; Shah and Shah, 2010; Jahanfar et al., 2014). Health professionals can create a safe and trusted environment for women, and are therefore in a unique position to facilitate disclosure and provide specific support (Edin, 2006; Mikton, 2010; Jahanfar et al., 2014). The 2009 Expert meeting on health sector responses to violence against women stated that screening for domestic violence during pregnancy is an exception to the insufficient evidence supporting screening in health care (WHO, 2010). A number of short screening instruments have proved to be relatively valid and reliable for use in health-care settings (Feder et al., 2009; Bailey, 2010; Mikton, 2010), and there is sufficient evidence that screening is accepted by pregnant women (Feder et al., 2009, Bailey, 2010; Stockl et al., 2013). However, a number of studies have shown that the application and acceptability of screening for domestic violence during pregnancy varies widely among health professionals (Plichta, 2004; Feder et al., 2009; Bailey, 2010; WHO, 2010). Systematic screening is not regularly applied by midwives, nurses and gynaecologists working in facilities in which special training is planned and/or which use specific protocols and guidelines (Morgan, 2003, Stenson et al., 2005; Lawoko et al., 2011). Studies in countries other than Italy have shown that the main reasons preventing midwives from dealing with domestic violence include a lack of knowledge (Morgan, 2003; Buck and Collins, 2007; Bailey, 2010; Lawoko et al., 2011), a lack of training (Morgan, 2003; Buck and Collins, 2007; Jeanjot et al., 2008; Finnbogadottir and Dykes, 2012), and the perception that violence is not a midwife's concern (Buck and Collins, 2007). To the best of our knowledge, pregnant women in Italy are not routinely asked questions about domestic violence and so we mainly concentrated on these three aspects in order to ensure the development of an effective screening programme.
Aims The objective of this study was to investigate the knowledge and experience of midwives in relation to the domestic violence during pregnancy, paying particular attention to the perception of their professional role and the acceptance of a screening programme for domestic violence during pregnancy.
Methods A qualitative phenomenological-hermeneutic study design (Denzin and Lincoln, 2011) was chosen because it is a suitable means of investigating the ideas and perceptions that shape people's behaviour (Greenhalgh and Taylor, 1997). All of the participants involved in the study were midwives working in the local health district of Monza and Brianza (northern Italy): four were practising in the community, and eleven worked at Monza's San Gerardo tertiary hospital, where about 3000 babies are delivered every year. They all recognised that domestic violence is an under-explored area in the context of Italian midwifery, and first attended a meeting at which it was explained that the aim of the study was to explore Italian midwives’ knowledge of domestic violence, and their attitude towards the use of screening. A purposive sample of 17 midwives was then invited to participate between July and October 2012; two declined to take part but, as data saturation was reached with the first 15 participants, no further interviews were scheduled. No incentives were provided.
The San Gerardo Hospital Ethics Committee approved the study, and data were treated strictly confidentially. It was emphasised that participation was voluntary and anonymous. The semi-structured interviews (Table 1), which lasted between 30 minutes and one hour, took place at the end of midwives’ working shifts at their workplace between July and October 2012. They were all audio-recorded with the participants’ permission and conducted by the same researcher (EM), who also prepared the verbatim transcriptions of their content. In some cases, additional questions were asked in order to explore further what emerged from the interview. Content analysis was used to identify the prominent themes without the aid of any software. The interviews were initially read several times by all of the researchers in order to obtain a general picture of their global meaning, after which labels were independently identified using verbatim quotations, and then discussed and revised until agreement was reached. Subsequently, the labels were grouped into meaningful units that were independently assembled into categories, and then discussed by all until agreement was reached. Finally, the same process was repeated in order to group the categories into themes. Each level of analysis is shown in Fig. 1. Throughout all of the stages of the data analysis, the researchers maintained a reflective attitude, continuously considered alternative interpretations of the interviewees’ phrases, and redefined their analysis (Pope and Mays, 2006). In order to improve reliability, the data derived from the interviews were triangulated with the participants (member checking) and, three months later, the 15 midwives were reinterviewed by phone and asked to express their agreement with each discovered theme.
Findings The average age of the surveyed midwives was 37 years (range 22–55), and their average working experience was 14 years (range eight months to 35 years). Ten midwives reported that they had never met a victim of domestic violence during their professional career; only two said they had received training concerning violence. The analysis of the interviews led to the formulation of three main themes (Fig. 1): ‘It is difficult to identify violence’; ‘There are various means we could use to detect violence’; and ‘The professionals involved’. It is difficult to identify violence The majority of the midwives said that it is difficult to recognise violence unless it has striking effects, and that it is easier to relate violence to physical signs (especially bruising): Well… I think that physical signs might be easier to recognise… but I'm not so sure because I have never met a battered woman who disclosed to me… so… besides physical signs – such as bruises – I don't know what else I could notice… (interview No. 2: MIDWIFE) Table 1 Interview grid. 1. What do you mean by domestic violence during pregnancy? 2. In your opinion, how widespread is domestic violence during pregnancy? 3. In your opinion, what are the risks of domestic violence during pregnancy? 4. What are the signs and symptoms related to domestic violence during pregnancy? 5. In your opinion, what are the most suitable professionals to recognise domestic violence? 6. What can help professionals to recognise domestic violence? 7. What do you think of the use of screening tools designed to detect domestic violence?
Please cite this article as: Mauri, E.M., et al., Domestic violence during pregnancy: Midwives experiences. Midwifery (2015), http://dx. doi.org/10.1016/j.midw.2015.02.002i
E.M. Mauri et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Hurry Many women
Lack of time
Cultural taboos
Theme no 1: It is difficult to identify violence
Lack of training Attention holistic approach dialogue
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judgment fear shame
Academic education Continuing education
Knowledge skills
Academic education
Midwives Psychologists Gynaecologists Social workers
Domestic violence during pregnancy
Multidisciplinarity is a resource
Clinical experience
Theme no 2: There are various means we could use to detect violence
Continuity of care
direct questions language barriers guide for midwives embarrassment remember the problem
Conflicting opinions about screening tools
Listening Confidence Feeling
Theme no 3: The professionals involved
Midwives play a crucial role
Support after birth Care Trusting relationship Fig. 1. Findings.
Psychological signs such as insecurity, anxiety, fear, low selfesteem and closure could also suggest something ‘strange’. Midwives sometimes have a feeling that ‘something is wrong’ when they notice a ‘strange relationship’ between the partners, or an aggressive attitude or obsessive controlling behaviour of the male partner. Nevertheless, this feeling does not always lead to recognition of the problem: … Well, we might sometimes foresee something… we might think that the woman has a strange behaviour… but we just stop there and don't ask anything so we actually don't know how many women are living in a violent environment at home. And these women might be alone … so we have to recognise them!!! (interview No. 6: MIDWIFE) Midwives relate their difficulty in recognising violence to a lack of training. Many of them said that they did not feel prepared to recognise signs of violence and would not know how to manage the situation if they had to. This leads them to avoid asking questions and contributes to keeping the phenomenon hidden: I think that our education about domestic violence is somehow… lacking. For example, I finished my academic studies as a midwife more than ten years ago and we never talked about this […] I don't know if things have changed now but I can say that continuing education is lacking too! (interview No. 10: SENIOR MIDWIFE) If I met a woman who suffered any kind of abuse, I would seek for help from my colleagues, from senior midwives or from a consultant to figure out what to do… because by myself, I really wouldn't know what to do! (interview No. 9: MIDWIFE) Besides the lack of training, the midwives highlighted other barriers to the identification of violence, such as a lack of time:
If I have to assess 20 women in a given time, I might only have 15 minutes for each one of them… how can I ask about violence? (interview No. 7: SENIOR MIDWIFE) A lack of individualisation and continuity of care also contributes to reducing the identification of violence: If we meet a woman just one time in the ward, it's really hard to build a trusting and intimate relationship so that she can feel safe to disclose the abuse… I think it could be easier to identify violence during prenatal visits, thanks to continuity of care… (interview No. 8: SENIOR MIDWIFE) It might be easier to identify violence if you know the woman… for example if you know her from her prenatal visits and you meet her again in the labour ward or the post-natal ward […] I mean, if you know her then maybe she would disclose the abuse, but if you meet her just once and for a few hours…then it's really hard! (interview No. 11: MIDWIFE) Additional barriers to the identification of violence are cultural taboos that prevent the women from disclosing abuse and the midwives from asking questions about domestic violence: I think that […] it's a hidden problem that women don't want to talk about because of feelings like shame and fear and because of cultural taboos, don't you think? That's why health professionals don't have a realistic perception of its extent and think it's less common than it actually is. (interview No. 14: MIDWIFE) […] You might feel that between partners […] there is something that's not right. But, again, you cannot always look into it and ask… because you could also have misunderstood the situation, right? (interview No. 11: MIDWIFE)
Please cite this article as: Mauri, E.M., et al., Domestic violence during pregnancy: Midwives experiences. Midwifery (2015), http://dx. doi.org/10.1016/j.midw.2015.02.002i
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E.M. Mauri et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
There are various means we could use to detect violence Some midwives pointed out that there is a need to implement academic and continuing education about violence in order to improve the knowledge, detection and management of intimate partner violence.: But […] I believe that dealing with violence cannot be improvised…you have to be really good at it… you have to be trained, because it's a really sensitive subject (interview No. 10: SENIOR MIDWIFE) It would be useful, now that I’ve graduated, to participate in congresses and courses about this, to improve my knowledge and skills in detecting and dealing with domestic violence… anyway, I think it would be better to improve first-level academic education on the subject so that all midwives can be equally trained in it (interview No. 6: MIDWIFE) Besides education, some midwives believe that clinical experience is essential to be able to identify what may be subtle signs of violence: […] I believe that clinical experience is what most helps you understand some kind of situations… I don't know… talking with women, exploring their stories… (interview No. 5: SISTER) Most of the midwives stated the importance of building a relationship with the woman in order to identify violence. In their opinion, this would help to create a trusting environment that would itself encourage the woman to disclose intimate issues such as domestic violence: If you don't build an intimate and trusting relationship with the woman, she will never disclose abuse. You could ask any question you want but she would never say a word… (interview n 8: SENIOR MIDWIFE) […] I have to trust you to disclose something that personal, you know? (interview No. 3: MIDWIFE) Relationships with the women, continuity of care, and sufficient time to assess and talk are critical to improving the identification of violence. Besides facilitating disclosure, midwives feel that these factors would help them to recognise the more subtle signs of violence: Obviously, the more you know the woman and the more frequently you meet her, the more you are able to understand or catch some signs, for example by observing the relationship between partners… (interview No. 4: SENIOR MIDWIFE) … Having time is also important! I'll say that again and again, because if you have to see a different woman every ten minutes, you have to focus on a few clinical aspects of pregnancy: blood tests, baby's growth… most of the times, it's like that, you know? It's sad… but we don't have time! (interview No. 15: SENIOR MIDWIFE) Moreover, the midwives highlighted the importance of being empathic and sensitive, listening and paying attention to the women so that they can feel safe and understood: You have to pay real attention to women and listen to them!!! […] If you pay more attention to a woman, she might disclose a problem without you even asking!! I think that's what really matters, paying attention to women! (interview No. 7: SENIOR MIDWIFE)
Screening tools designed to detect violence are available, but the midwives had different feelings and conflicting opinions about them. On one hand, they said that a screening tool might be useful to remind health professionals of the problem and offer the women an opportunity for disclosure: Anyway… yes… I think that a screening tool could also help health professionals to think about violence, as we often forget it (interview No. 5: SISTER) …screening might have some benefits…yes! For example, if directly asked, you are somehow compelled to face the problem, so maybe this could be an opportunity for disclosure. If not asked, one might never talk about it… (interview No. 10: SENIOR MIDWIFE) On the other hand, some midwives are afraid that women might be offended by the screening questions, and point out that this could damage the tool’s effectiveness and viability, although some said that being in a trusting relationship with the woman and explaining the reasons for the screening prevents the risk of offending: Asking about domestic violence might be embarrassing for both battered and non-battered women… and probably it doesn't help disclosure (interview No. 10: SENIOR MIDWIFE) Well… the only disadvantage of screening that comes to mind is that a woman who never suffered any kind of violence might be offended by our questioning… Anyway, I think that if we explained to the women why we are doing this, they would understand. (interview No. 6: MIDWIFE) The professionals involved Most of the midwives believe that all of the health professionals involved in caring for childbearing women should be able to identify signs of physical and psychological violence: I believe that all of the health professionals who come across pregnant women should be trained and able to detect violence exactly because our mission is the mother's and baby's health and well-being (interview No. 14: MIDWIFE) Among all maternity health professionals, midwives are in a privileged position because of the particular trusting relationship that they can build with women: … Fortunately, as midwives, we have a peculiarity if compared to gynaecologists: we can build a trusting relationship with the woman, and we have a sensitivity that most of the times physicians might not have… just because of their different professional profile and educational background (interview No. 8: SENIOR MIDWIFE) The majority of the interviewees recognised that it is a midwife's job and responsibility to detect violence among childbearing women, and to provide a first prompt, adequate and expert response. Some thought they are like bridges: they can identify abused women but have to refer them to dedicated professionals: A midwife can take a woman into care in order to refer her to a competent professional such as a psychologist, a social worker or someone else who can help her […] I think that as midwives we can't manage the whole situation all by ourselves… at least… I don't think I'd have the expertise to do so… I wouldn't really know what to do, I really wouldn't!!! (interview No. 11: MIDWIFE)
Please cite this article as: Mauri, E.M., et al., Domestic violence during pregnancy: Midwives experiences. Midwifery (2015), http://dx. doi.org/10.1016/j.midw.2015.02.002i
E.M. Mauri et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Although it was considered that midwives play a crucial role for abused women, the majority of the interviewees emphasised the fact that midwives cannot take charge of the situation all by themselves: …We cannot presume we can do everything by ourselves because, even if trained and being able to improve our skills, we might need some help […] (interview No. 1: MIDWIFE) It was pointed out that an interdisciplinary approach is an important resource when talking about domestic violence. A number of midwives stated that collaboration among professionals is needed in both detecting and managing violence: Collaborating in such situations is always useful: it helps us and it helps the women (interview No. 1: MIDWIFE) I mean, not just by the midwife or gynaecologist… the woman must be looked after by a team of professionals (interview No. 7: SENIOR MIDWIFE) Following the data analysis, a questionnaire was created that consisted of three items corresponding to the main themes emerging from the interviews. The 15 midwives were reinterviewed by phone and asked to express their level of agreement with each discovered theme using a 4-point Likert scale: completely agree, partly agree, partly disagree and completely disagree. The midwives showed a high level of agreement concerning theme No. 1; regarding theme No. 2, one midwife stated that in order to overcome the fear of offending women, the screening should not be administered during the first antenatal visit: and regarding theme No. 3, two midwives stated that it is not essential to be a midwife in order to recognise domestic violence, but it is neccessary to be sensitive and careful in the relationship.
Discussion It emerged from our interviews that domestic violence is hard to detect. Midwives feel they are unprepared to identify signs of violence and manage the situation appropriately because of a lack of training. Other qualitative and quantitative studies conducted in various countries have shown that a lack of education and training in domestic violence is an important issue for midwives (Roelens et al., 2006; Jack et al., 2008; Finnbogadottir and Dykes, 2012; Sprague et al., 2012). Previous studies have showed the effectiveness of educational programmes concerning domestic violence (Salmon et al., 2006; Baird et al., 2013), which were positively received by participants and were also associated with improvements in their knowledge of and confidence in dealing with domestic violence. Education is therefore crucial. Like those of other researches (Watts, 2004; Jack et al., 2008), our study shows that midwives would like good professional training in order to be able to feel that they competently deal with violence and satisfy the needs of battered women. Watts (2004) stated that continuing education, including training on the job programmes, aptitude tests and constant updating should be offered to all gynaecological and obstetric staff, and the need for further training and supervision strongly emerges from our study and that of Finnbogadottir and Dykes (2012). However, further studies are needed to determine which educational programme guarantees better outcomes (Sharps et al., 2008). In addition to training and education, the midwives highlighted the fact that maternity care could be improved by promoting continuity of care, one-to-one care, and personalised care. The interviewees pointed out that continuity of care is one of the best ways of building trusting and personalised relationships that would make women feel comfortable enough to disclose abuse
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(Hindin, 2006; Liebschutz et al., 2008). In line with other studies, another crucial issue to emerge when midwives think about detecting violence was having enough time to dedicate to each woman during ante- and postnatal visits (Jack et al., 2008; Bailey, 2010; Finnbogadottir and Dykes, 2012). According to the interviewees, time is essential in order to allow midwives to notice any sign of violence, and allow women to get to know and trust their midwife enough to disclose abuse. The interviewed midwives expressed contrasting feelings about routine screening for domestic violence during pregnancy and post partum: most of them (80%) highlighted the potential benefits, but others pointed out the limitations of asking about violence. The main benefits were that screening would remind midwives and gynaecologists of the issue, offer an opportunity for disclosure, and make it possible to detect violence and provide help and support to a larger number of women. These positive sides of screening were also identified by women in a review by Feder et al. (2009) but, despite their recognition of the benefits of using a screening test, Lanzenbatt et al. discovered that only 50% of their midwives were in favour of routine screening for all pregnant women (Lazenbatt et al., 2009). The midwives considered their relationship with the women as a key factor in the effectiveness of screening, and this is supported by the conclusions of other qualitative studies of midwives' perceptions of screening (Hindin, 2006; Jack et al., 2008; Liebschutz et al., 2008; Feder et al., 2009; Sprague et al., 2012). Studies of battered women's views of domestic violence screening have also found that, when a health professional can sensitively and non-judgementally ask about violence in a confidential environment, women feel supported, cared for and understood, and relieved that someone is finally talking to them about it (Feder et al., 2009). Concern about offending women stands out as one of the limitations of screening mentioned by the midwives in our study, and stimulated them to consider carefully right questions to ask, which has also been found in other studies (Ramsay et al., 2002; Chambliss, 2008; Finnbogadottir and Dykes, 2012). However a recent study (Salmon et al., 2013) has shown that interviewees subject to abuse during pregnancy are happy to be questioned, even though they do not always feel able to disclose immediately. Some of the midwives raised doubts about the effectiveness of direct questioning because they were worried about offending, distancing and shutting out the women. These concerns have also been identified in other qualitative studies (Jack et al., 2008; Finnbogadottir and Dykes, 2012), although some have recognised that direct questions have the advantage of increasing violence detection rates (Bailey, 2010). Other barriers to implementing screening by midwives mentioned in other studies include a lack of effective intervention programmes, a lack of time and privacy, a lack of specific professional training, a fear of ‘opening Pandora's box’, a lack of knowledge concerning other local services dedicated to victims of violence, and the fear of retaliation against women (Roelens et al., 2006; Chambliss (2008); Sharps et al., 2008; Bailey, 2010; Finnbogadottir and Dykes, 2012). Previous studies have also found that a barrier to asking about domestic violence was the reluctance of a partner to leave the consultation (Lazenbatt et al., 2009; Baird et al., 2013) Sixty per cent of the interviewed midwives stated that the interdisciplinary management of violence is essential, and other studies have also pointed out the need for a interdisciplinary approach (Chambliss (2008); Finnbogadottir and Dykes, 2012). According to Chambliss (2008), violence cannot be managed by one single professional at a time but needs comprehensive efforts combining the resources of the judiciary, law enforcement and health-care agencies, educational systems, and other social institutions.
Please cite this article as: Mauri, E.M., et al., Domestic violence during pregnancy: Midwives experiences. Midwifery (2015), http://dx. doi.org/10.1016/j.midw.2015.02.002i
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Conclusions
Acknowledgements
The findings of this study show that domestic violence is a hidden and difficult to detect problem, partially because of cultural taboos but also because of a lack of education and training: only the most striking situations or the presence of evident physical signs make midwives suspect violence. Midwives have little knowledge of the subject and feel unprepared to deal with it, which is why they think that implementing specific training programmes would be helpful. Our findings also highlight the importance of clinical experience, relationships with the women and continuity of care in detecting violence. The contrasting feelings and positions expressed about the universal screening of domestic violence during pregnancy and post partum reveal a need for further reflections concerning ‘the right questions to ask’ and ‘how to ask them’. Most of the interviewees thought that all midwives and gynaecologists should be trained to detect violence, but consider that midwives can play a particular role because of their sensitivity and proximity to the women. They should be able to recognise violence in the first place, offer first-level support and help, and then refer battered women to dedicated professionals or groups of professionals. It is still not clear who should take responsibility for the care of these women (psychologists, social workers, shelters or other community-based services), just as there is still uncertainty as to which interventions are more effective in reducing violence and improving maternal and foetal outcomes (Jahanfar et al., 2014). However, in order to offer women competent and global support, it seems that an interdisciplinary approach by different professionals is necessary. This study investigated an issue that has been poorly explored in the Italian context. It highlights the fact that midwives recognise their fundamental role in detecting domestic violence, but also acknowledge the need for more training and, above all, collaboration among professionals even though the fact that the Italian national health service does not guarantee continuity of care makes it more difficult to identify domestic violence. Finally it emerged that there are also cultural taboos that prevent the identification of violence.
We would like to thank the participating midwives who made this study possible.
Practical implications Given the prevalence of domestic violence during pregnancy and its negative consequences on maternal and foetal health, it seems to be essential to implement first-level and continuing education for midwives on the subject. Given the lack of specific data concerning domestic violence during pregnancy in Italy, further studies are needed in order to assess its prevalence, the knowledge and competences of midwives, and the use of screening tools (which might need cultural adjustment). It is also fundamental to collaborate with other professionals in order to develop shared health-care pathways.
Study limitations Although every effort was made to ensure a rigorous approach, the study has some important limitations. Firstly, we recruited midwives employed in the same health district and, secondly, although we recruited both hospital and community midwives, the latter were less representative (11 versus four). Conflict of interest The authors declare that they have no conflict of interest.
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Midwifery journal homepage: www.elsevier.com/midw
Domestic violence during pregnancy: Midwives experiences Elisa Marta Mauri, RM, BMid (Midwife)a, Antonella Nespoli, RM, BMid, MSc (Research Midwife)b, Giuseppina Persico, RM, BMid, MSc, PhD in Physiopathological, Neuropsychobiological Sciences and Life-Cycle Care (Lecturer in Midwifery)b, Virna Franca Zobbi, RM, BMid, MSc, PhD in Nursing and Midwifery Science (Lecturer in Midwifery)b,n a b
John Radcliffe Hospital, OUH, Headley Way, Oxford, OX3 9DU, UK Department of Surgery and Translational Medicine, University of Milano-Bicocca, via Cadore 48, 20900 Monza (MB), Italy
art ic l e i nf o
a b s t r a c t
Article history: Received 11 June 2014 Received in revised form 3 February 2015 Accepted 4 February 2015
Objective: the aim of this qualitative study was to explore midwives' knowledge and clinical experience of domestic violence among pregnant women, with particular emphasis on their perceptions of their professional role. Design: the data collected for this phenomenological-hermeneutical qualitative study were collected using semi-structured interviews, and analysed according to Denzin and Lincoln (2011). Setting and participants: fifteen hospital and community midwives working in the local health district of Monza and Brianza in northern Italy were recruited between July and October 2012. Findings: three main themes emerged: ‘it is difficult to recognise domestic violence’ because of a limited knowledge of the most common signs and symptoms of violence, a lack of training, cultural taboos, and the women's unwillingness to disclose abuse; ‘we have a certain number of means of identifying violence’, such as relationships with the woman, specific professional training and screening tools, which have advantages and disadvantages; ‘the professionals involved’ in identifying and managing family violence highlight the importance of a interdisciplinary approach. Key conclusions and implications for practice: midwives acknowledge their crucial role in identifying and managing domestic violence but are still unprepared to do so and indicate various barriers that need to be overcome. There is a need to implement basic university education on the subject and provide specific professional training. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Domestic violence Intimate partner violence Pregnancy Universal screening Midwives
Introduction Domestic violence during pregnancy Domestic violence during pregnancy is a major public health issue that threatens the health of mothers and foetuses (Janssen et al., 2003; Plichta, 2004; Chambliss, 2008; Sharps et al., 2008; Bailey, 2010; Mikton, 2010). International studies have found differences in the prevalence of domestic violence during pregnancy ranging from 1% to 20% (Jasinski, 2004; Motta et al., 2014), which have been attributed to cultural differences between countries, different definitions of domestic abuse, different means of detecting abuse, and differences in study designs (Edin, 2006; Bailey, 2010). Only a few studies have investigated its prevalence n
Corresponding author. E-mail addresses: [email protected] (E.M. Mauri), [email protected] (A. Nespoli), [email protected] (G. Persico), [email protected] (V.F. Zobbi).
in Italy: Dubini and Curiel (2004) found that 22% of about 300 pregnant women interviewed in some clinics in Florence had experienced violence while pregnant, and a survey published by the National Institute of Statistics' (ISTAT) in 2007 indicated that 11.5% of pregnant women were victims of domestic violence (ISTAT, 2007). Similar rates have been found in Nicaragua, Turkey, Pakistan, Belgium, India, the USA and New Zealand (Bailey, 2010), England (Women's Aid Federation of England, 2012), Canada (Wathen et al., 2003), the Congo, Colombia, Uganda (Devries et al., 2010) and Australia (Phillips and Malcolm, 2006). There is disagreement in the literature as to whether the prevalence of domestic violence decreases during pregnancy, remains about the same, or increases (Bailey, 2010). The 2007 ISTAT survey indicated that violence had begun during pregnancy in 15% of cases, escalated during pregnancy in 16.6%, and remained unchanged in 50.6% (ISTAT, 2007). Pregnancy can therefore trigger or exacerbate violence against women, and may sometimes be the consequence of violence. Pregnant women subjected to domestic abuse are considered at
http://dx.doi.org/10.1016/j.midw.2015.02.002 0266-6138/& 2015 Elsevier Ltd. All rights reserved.
Please cite this article as: Mauri, E.M., et al., Domestic violence during pregnancy: Midwives experiences. Midwifery (2015), http://dx. doi.org/10.1016/j.midw.2015.02.002i
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high risk because exposure to physical, sexual or psychological violence during pregnancy correlates with increased maternal, foetal and infant morbidity and mortality (Janssen et al., 2003; Bacchus et al., 2004; Plichta, 2004; Mezey et al., 2005; Chambliss, 2008; Romito et al., 2008; Sharps et al., 2008; Bailey, 2010; Shah and Shah, 2010; Jahanfar et al., 2014). Health professionals can create a safe and trusted environment for women, and are therefore in a unique position to facilitate disclosure and provide specific support (Edin, 2006; Mikton, 2010; Jahanfar et al., 2014). The 2009 Expert meeting on health sector responses to violence against women stated that screening for domestic violence during pregnancy is an exception to the insufficient evidence supporting screening in health care (WHO, 2010). A number of short screening instruments have proved to be relatively valid and reliable for use in health-care settings (Feder et al., 2009; Bailey, 2010; Mikton, 2010), and there is sufficient evidence that screening is accepted by pregnant women (Feder et al., 2009, Bailey, 2010; Stockl et al., 2013). However, a number of studies have shown that the application and acceptability of screening for domestic violence during pregnancy varies widely among health professionals (Plichta, 2004; Feder et al., 2009; Bailey, 2010; WHO, 2010). Systematic screening is not regularly applied by midwives, nurses and gynaecologists working in facilities in which special training is planned and/or which use specific protocols and guidelines (Morgan, 2003, Stenson et al., 2005; Lawoko et al., 2011). Studies in countries other than Italy have shown that the main reasons preventing midwives from dealing with domestic violence include a lack of knowledge (Morgan, 2003; Buck and Collins, 2007; Bailey, 2010; Lawoko et al., 2011), a lack of training (Morgan, 2003; Buck and Collins, 2007; Jeanjot et al., 2008; Finnbogadottir and Dykes, 2012), and the perception that violence is not a midwife's concern (Buck and Collins, 2007). To the best of our knowledge, pregnant women in Italy are not routinely asked questions about domestic violence and so we mainly concentrated on these three aspects in order to ensure the development of an effective screening programme.
Aims The objective of this study was to investigate the knowledge and experience of midwives in relation to the domestic violence during pregnancy, paying particular attention to the perception of their professional role and the acceptance of a screening programme for domestic violence during pregnancy.
Methods A qualitative phenomenological-hermeneutic study design (Denzin and Lincoln, 2011) was chosen because it is a suitable means of investigating the ideas and perceptions that shape people's behaviour (Greenhalgh and Taylor, 1997). All of the participants involved in the study were midwives working in the local health district of Monza and Brianza (northern Italy): four were practising in the community, and eleven worked at Monza's San Gerardo tertiary hospital, where about 3000 babies are delivered every year. They all recognised that domestic violence is an under-explored area in the context of Italian midwifery, and first attended a meeting at which it was explained that the aim of the study was to explore Italian midwives’ knowledge of domestic violence, and their attitude towards the use of screening. A purposive sample of 17 midwives was then invited to participate between July and October 2012; two declined to take part but, as data saturation was reached with the first 15 participants, no further interviews were scheduled. No incentives were provided.
The San Gerardo Hospital Ethics Committee approved the study, and data were treated strictly confidentially. It was emphasised that participation was voluntary and anonymous. The semi-structured interviews (Table 1), which lasted between 30 minutes and one hour, took place at the end of midwives’ working shifts at their workplace between July and October 2012. They were all audio-recorded with the participants’ permission and conducted by the same researcher (EM), who also prepared the verbatim transcriptions of their content. In some cases, additional questions were asked in order to explore further what emerged from the interview. Content analysis was used to identify the prominent themes without the aid of any software. The interviews were initially read several times by all of the researchers in order to obtain a general picture of their global meaning, after which labels were independently identified using verbatim quotations, and then discussed and revised until agreement was reached. Subsequently, the labels were grouped into meaningful units that were independently assembled into categories, and then discussed by all until agreement was reached. Finally, the same process was repeated in order to group the categories into themes. Each level of analysis is shown in Fig. 1. Throughout all of the stages of the data analysis, the researchers maintained a reflective attitude, continuously considered alternative interpretations of the interviewees’ phrases, and redefined their analysis (Pope and Mays, 2006). In order to improve reliability, the data derived from the interviews were triangulated with the participants (member checking) and, three months later, the 15 midwives were reinterviewed by phone and asked to express their agreement with each discovered theme.
Findings The average age of the surveyed midwives was 37 years (range 22–55), and their average working experience was 14 years (range eight months to 35 years). Ten midwives reported that they had never met a victim of domestic violence during their professional career; only two said they had received training concerning violence. The analysis of the interviews led to the formulation of three main themes (Fig. 1): ‘It is difficult to identify violence’; ‘There are various means we could use to detect violence’; and ‘The professionals involved’. It is difficult to identify violence The majority of the midwives said that it is difficult to recognise violence unless it has striking effects, and that it is easier to relate violence to physical signs (especially bruising): Well… I think that physical signs might be easier to recognise… but I'm not so sure because I have never met a battered woman who disclosed to me… so… besides physical signs – such as bruises – I don't know what else I could notice… (interview No. 2: MIDWIFE) Table 1 Interview grid. 1. What do you mean by domestic violence during pregnancy? 2. In your opinion, how widespread is domestic violence during pregnancy? 3. In your opinion, what are the risks of domestic violence during pregnancy? 4. What are the signs and symptoms related to domestic violence during pregnancy? 5. In your opinion, what are the most suitable professionals to recognise domestic violence? 6. What can help professionals to recognise domestic violence? 7. What do you think of the use of screening tools designed to detect domestic violence?
Please cite this article as: Mauri, E.M., et al., Domestic violence during pregnancy: Midwives experiences. Midwifery (2015), http://dx. doi.org/10.1016/j.midw.2015.02.002i
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Hurry Many women
Lack of time
Cultural taboos
Theme no 1: It is difficult to identify violence
Lack of training Attention holistic approach dialogue
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judgment fear shame
Academic education Continuing education
Knowledge skills
Academic education
Midwives Psychologists Gynaecologists Social workers
Domestic violence during pregnancy
Multidisciplinarity is a resource
Clinical experience
Theme no 2: There are various means we could use to detect violence
Continuity of care
direct questions language barriers guide for midwives embarrassment remember the problem
Conflicting opinions about screening tools
Listening Confidence Feeling
Theme no 3: The professionals involved
Midwives play a crucial role
Support after birth Care Trusting relationship Fig. 1. Findings.
Psychological signs such as insecurity, anxiety, fear, low selfesteem and closure could also suggest something ‘strange’. Midwives sometimes have a feeling that ‘something is wrong’ when they notice a ‘strange relationship’ between the partners, or an aggressive attitude or obsessive controlling behaviour of the male partner. Nevertheless, this feeling does not always lead to recognition of the problem: … Well, we might sometimes foresee something… we might think that the woman has a strange behaviour… but we just stop there and don't ask anything so we actually don't know how many women are living in a violent environment at home. And these women might be alone … so we have to recognise them!!! (interview No. 6: MIDWIFE) Midwives relate their difficulty in recognising violence to a lack of training. Many of them said that they did not feel prepared to recognise signs of violence and would not know how to manage the situation if they had to. This leads them to avoid asking questions and contributes to keeping the phenomenon hidden: I think that our education about domestic violence is somehow… lacking. For example, I finished my academic studies as a midwife more than ten years ago and we never talked about this […] I don't know if things have changed now but I can say that continuing education is lacking too! (interview No. 10: SENIOR MIDWIFE) If I met a woman who suffered any kind of abuse, I would seek for help from my colleagues, from senior midwives or from a consultant to figure out what to do… because by myself, I really wouldn't know what to do! (interview No. 9: MIDWIFE) Besides the lack of training, the midwives highlighted other barriers to the identification of violence, such as a lack of time:
If I have to assess 20 women in a given time, I might only have 15 minutes for each one of them… how can I ask about violence? (interview No. 7: SENIOR MIDWIFE) A lack of individualisation and continuity of care also contributes to reducing the identification of violence: If we meet a woman just one time in the ward, it's really hard to build a trusting and intimate relationship so that she can feel safe to disclose the abuse… I think it could be easier to identify violence during prenatal visits, thanks to continuity of care… (interview No. 8: SENIOR MIDWIFE) It might be easier to identify violence if you know the woman… for example if you know her from her prenatal visits and you meet her again in the labour ward or the post-natal ward […] I mean, if you know her then maybe she would disclose the abuse, but if you meet her just once and for a few hours…then it's really hard! (interview No. 11: MIDWIFE) Additional barriers to the identification of violence are cultural taboos that prevent the women from disclosing abuse and the midwives from asking questions about domestic violence: I think that […] it's a hidden problem that women don't want to talk about because of feelings like shame and fear and because of cultural taboos, don't you think? That's why health professionals don't have a realistic perception of its extent and think it's less common than it actually is. (interview No. 14: MIDWIFE) […] You might feel that between partners […] there is something that's not right. But, again, you cannot always look into it and ask… because you could also have misunderstood the situation, right? (interview No. 11: MIDWIFE)
Please cite this article as: Mauri, E.M., et al., Domestic violence during pregnancy: Midwives experiences. Midwifery (2015), http://dx. doi.org/10.1016/j.midw.2015.02.002i
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There are various means we could use to detect violence Some midwives pointed out that there is a need to implement academic and continuing education about violence in order to improve the knowledge, detection and management of intimate partner violence.: But […] I believe that dealing with violence cannot be improvised…you have to be really good at it… you have to be trained, because it's a really sensitive subject (interview No. 10: SENIOR MIDWIFE) It would be useful, now that I’ve graduated, to participate in congresses and courses about this, to improve my knowledge and skills in detecting and dealing with domestic violence… anyway, I think it would be better to improve first-level academic education on the subject so that all midwives can be equally trained in it (interview No. 6: MIDWIFE) Besides education, some midwives believe that clinical experience is essential to be able to identify what may be subtle signs of violence: […] I believe that clinical experience is what most helps you understand some kind of situations… I don't know… talking with women, exploring their stories… (interview No. 5: SISTER) Most of the midwives stated the importance of building a relationship with the woman in order to identify violence. In their opinion, this would help to create a trusting environment that would itself encourage the woman to disclose intimate issues such as domestic violence: If you don't build an intimate and trusting relationship with the woman, she will never disclose abuse. You could ask any question you want but she would never say a word… (interview n 8: SENIOR MIDWIFE) […] I have to trust you to disclose something that personal, you know? (interview No. 3: MIDWIFE) Relationships with the women, continuity of care, and sufficient time to assess and talk are critical to improving the identification of violence. Besides facilitating disclosure, midwives feel that these factors would help them to recognise the more subtle signs of violence: Obviously, the more you know the woman and the more frequently you meet her, the more you are able to understand or catch some signs, for example by observing the relationship between partners… (interview No. 4: SENIOR MIDWIFE) … Having time is also important! I'll say that again and again, because if you have to see a different woman every ten minutes, you have to focus on a few clinical aspects of pregnancy: blood tests, baby's growth… most of the times, it's like that, you know? It's sad… but we don't have time! (interview No. 15: SENIOR MIDWIFE) Moreover, the midwives highlighted the importance of being empathic and sensitive, listening and paying attention to the women so that they can feel safe and understood: You have to pay real attention to women and listen to them!!! […] If you pay more attention to a woman, she might disclose a problem without you even asking!! I think that's what really matters, paying attention to women! (interview No. 7: SENIOR MIDWIFE)
Screening tools designed to detect violence are available, but the midwives had different feelings and conflicting opinions about them. On one hand, they said that a screening tool might be useful to remind health professionals of the problem and offer the women an opportunity for disclosure: Anyway… yes… I think that a screening tool could also help health professionals to think about violence, as we often forget it (interview No. 5: SISTER) …screening might have some benefits…yes! For example, if directly asked, you are somehow compelled to face the problem, so maybe this could be an opportunity for disclosure. If not asked, one might never talk about it… (interview No. 10: SENIOR MIDWIFE) On the other hand, some midwives are afraid that women might be offended by the screening questions, and point out that this could damage the tool’s effectiveness and viability, although some said that being in a trusting relationship with the woman and explaining the reasons for the screening prevents the risk of offending: Asking about domestic violence might be embarrassing for both battered and non-battered women… and probably it doesn't help disclosure (interview No. 10: SENIOR MIDWIFE) Well… the only disadvantage of screening that comes to mind is that a woman who never suffered any kind of violence might be offended by our questioning… Anyway, I think that if we explained to the women why we are doing this, they would understand. (interview No. 6: MIDWIFE) The professionals involved Most of the midwives believe that all of the health professionals involved in caring for childbearing women should be able to identify signs of physical and psychological violence: I believe that all of the health professionals who come across pregnant women should be trained and able to detect violence exactly because our mission is the mother's and baby's health and well-being (interview No. 14: MIDWIFE) Among all maternity health professionals, midwives are in a privileged position because of the particular trusting relationship that they can build with women: … Fortunately, as midwives, we have a peculiarity if compared to gynaecologists: we can build a trusting relationship with the woman, and we have a sensitivity that most of the times physicians might not have… just because of their different professional profile and educational background (interview No. 8: SENIOR MIDWIFE) The majority of the interviewees recognised that it is a midwife's job and responsibility to detect violence among childbearing women, and to provide a first prompt, adequate and expert response. Some thought they are like bridges: they can identify abused women but have to refer them to dedicated professionals: A midwife can take a woman into care in order to refer her to a competent professional such as a psychologist, a social worker or someone else who can help her […] I think that as midwives we can't manage the whole situation all by ourselves… at least… I don't think I'd have the expertise to do so… I wouldn't really know what to do, I really wouldn't!!! (interview No. 11: MIDWIFE)
Please cite this article as: Mauri, E.M., et al., Domestic violence during pregnancy: Midwives experiences. Midwifery (2015), http://dx. doi.org/10.1016/j.midw.2015.02.002i
E.M. Mauri et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Although it was considered that midwives play a crucial role for abused women, the majority of the interviewees emphasised the fact that midwives cannot take charge of the situation all by themselves: …We cannot presume we can do everything by ourselves because, even if trained and being able to improve our skills, we might need some help […] (interview No. 1: MIDWIFE) It was pointed out that an interdisciplinary approach is an important resource when talking about domestic violence. A number of midwives stated that collaboration among professionals is needed in both detecting and managing violence: Collaborating in such situations is always useful: it helps us and it helps the women (interview No. 1: MIDWIFE) I mean, not just by the midwife or gynaecologist… the woman must be looked after by a team of professionals (interview No. 7: SENIOR MIDWIFE) Following the data analysis, a questionnaire was created that consisted of three items corresponding to the main themes emerging from the interviews. The 15 midwives were reinterviewed by phone and asked to express their level of agreement with each discovered theme using a 4-point Likert scale: completely agree, partly agree, partly disagree and completely disagree. The midwives showed a high level of agreement concerning theme No. 1; regarding theme No. 2, one midwife stated that in order to overcome the fear of offending women, the screening should not be administered during the first antenatal visit: and regarding theme No. 3, two midwives stated that it is not essential to be a midwife in order to recognise domestic violence, but it is neccessary to be sensitive and careful in the relationship.
Discussion It emerged from our interviews that domestic violence is hard to detect. Midwives feel they are unprepared to identify signs of violence and manage the situation appropriately because of a lack of training. Other qualitative and quantitative studies conducted in various countries have shown that a lack of education and training in domestic violence is an important issue for midwives (Roelens et al., 2006; Jack et al., 2008; Finnbogadottir and Dykes, 2012; Sprague et al., 2012). Previous studies have showed the effectiveness of educational programmes concerning domestic violence (Salmon et al., 2006; Baird et al., 2013), which were positively received by participants and were also associated with improvements in their knowledge of and confidence in dealing with domestic violence. Education is therefore crucial. Like those of other researches (Watts, 2004; Jack et al., 2008), our study shows that midwives would like good professional training in order to be able to feel that they competently deal with violence and satisfy the needs of battered women. Watts (2004) stated that continuing education, including training on the job programmes, aptitude tests and constant updating should be offered to all gynaecological and obstetric staff, and the need for further training and supervision strongly emerges from our study and that of Finnbogadottir and Dykes (2012). However, further studies are needed to determine which educational programme guarantees better outcomes (Sharps et al., 2008). In addition to training and education, the midwives highlighted the fact that maternity care could be improved by promoting continuity of care, one-to-one care, and personalised care. The interviewees pointed out that continuity of care is one of the best ways of building trusting and personalised relationships that would make women feel comfortable enough to disclose abuse
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(Hindin, 2006; Liebschutz et al., 2008). In line with other studies, another crucial issue to emerge when midwives think about detecting violence was having enough time to dedicate to each woman during ante- and postnatal visits (Jack et al., 2008; Bailey, 2010; Finnbogadottir and Dykes, 2012). According to the interviewees, time is essential in order to allow midwives to notice any sign of violence, and allow women to get to know and trust their midwife enough to disclose abuse. The interviewed midwives expressed contrasting feelings about routine screening for domestic violence during pregnancy and post partum: most of them (80%) highlighted the potential benefits, but others pointed out the limitations of asking about violence. The main benefits were that screening would remind midwives and gynaecologists of the issue, offer an opportunity for disclosure, and make it possible to detect violence and provide help and support to a larger number of women. These positive sides of screening were also identified by women in a review by Feder et al. (2009) but, despite their recognition of the benefits of using a screening test, Lanzenbatt et al. discovered that only 50% of their midwives were in favour of routine screening for all pregnant women (Lazenbatt et al., 2009). The midwives considered their relationship with the women as a key factor in the effectiveness of screening, and this is supported by the conclusions of other qualitative studies of midwives' perceptions of screening (Hindin, 2006; Jack et al., 2008; Liebschutz et al., 2008; Feder et al., 2009; Sprague et al., 2012). Studies of battered women's views of domestic violence screening have also found that, when a health professional can sensitively and non-judgementally ask about violence in a confidential environment, women feel supported, cared for and understood, and relieved that someone is finally talking to them about it (Feder et al., 2009). Concern about offending women stands out as one of the limitations of screening mentioned by the midwives in our study, and stimulated them to consider carefully right questions to ask, which has also been found in other studies (Ramsay et al., 2002; Chambliss, 2008; Finnbogadottir and Dykes, 2012). However a recent study (Salmon et al., 2013) has shown that interviewees subject to abuse during pregnancy are happy to be questioned, even though they do not always feel able to disclose immediately. Some of the midwives raised doubts about the effectiveness of direct questioning because they were worried about offending, distancing and shutting out the women. These concerns have also been identified in other qualitative studies (Jack et al., 2008; Finnbogadottir and Dykes, 2012), although some have recognised that direct questions have the advantage of increasing violence detection rates (Bailey, 2010). Other barriers to implementing screening by midwives mentioned in other studies include a lack of effective intervention programmes, a lack of time and privacy, a lack of specific professional training, a fear of ‘opening Pandora's box’, a lack of knowledge concerning other local services dedicated to victims of violence, and the fear of retaliation against women (Roelens et al., 2006; Chambliss (2008); Sharps et al., 2008; Bailey, 2010; Finnbogadottir and Dykes, 2012). Previous studies have also found that a barrier to asking about domestic violence was the reluctance of a partner to leave the consultation (Lazenbatt et al., 2009; Baird et al., 2013) Sixty per cent of the interviewed midwives stated that the interdisciplinary management of violence is essential, and other studies have also pointed out the need for a interdisciplinary approach (Chambliss (2008); Finnbogadottir and Dykes, 2012). According to Chambliss (2008), violence cannot be managed by one single professional at a time but needs comprehensive efforts combining the resources of the judiciary, law enforcement and health-care agencies, educational systems, and other social institutions.
Please cite this article as: Mauri, E.M., et al., Domestic violence during pregnancy: Midwives experiences. Midwifery (2015), http://dx. doi.org/10.1016/j.midw.2015.02.002i
E.M. Mauri et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Conclusions
Acknowledgements
The findings of this study show that domestic violence is a hidden and difficult to detect problem, partially because of cultural taboos but also because of a lack of education and training: only the most striking situations or the presence of evident physical signs make midwives suspect violence. Midwives have little knowledge of the subject and feel unprepared to deal with it, which is why they think that implementing specific training programmes would be helpful. Our findings also highlight the importance of clinical experience, relationships with the women and continuity of care in detecting violence. The contrasting feelings and positions expressed about the universal screening of domestic violence during pregnancy and post partum reveal a need for further reflections concerning ‘the right questions to ask’ and ‘how to ask them’. Most of the interviewees thought that all midwives and gynaecologists should be trained to detect violence, but consider that midwives can play a particular role because of their sensitivity and proximity to the women. They should be able to recognise violence in the first place, offer first-level support and help, and then refer battered women to dedicated professionals or groups of professionals. It is still not clear who should take responsibility for the care of these women (psychologists, social workers, shelters or other community-based services), just as there is still uncertainty as to which interventions are more effective in reducing violence and improving maternal and foetal outcomes (Jahanfar et al., 2014). However, in order to offer women competent and global support, it seems that an interdisciplinary approach by different professionals is necessary. This study investigated an issue that has been poorly explored in the Italian context. It highlights the fact that midwives recognise their fundamental role in detecting domestic violence, but also acknowledge the need for more training and, above all, collaboration among professionals even though the fact that the Italian national health service does not guarantee continuity of care makes it more difficult to identify domestic violence. Finally it emerged that there are also cultural taboos that prevent the identification of violence.
We would like to thank the participating midwives who made this study possible.
Practical implications Given the prevalence of domestic violence during pregnancy and its negative consequences on maternal and foetal health, it seems to be essential to implement first-level and continuing education for midwives on the subject. Given the lack of specific data concerning domestic violence during pregnancy in Italy, further studies are needed in order to assess its prevalence, the knowledge and competences of midwives, and the use of screening tools (which might need cultural adjustment). It is also fundamental to collaborate with other professionals in order to develop shared health-care pathways.
Study limitations Although every effort was made to ensure a rigorous approach, the study has some important limitations. Firstly, we recruited midwives employed in the same health district and, secondly, although we recruited both hospital and community midwives, the latter were less representative (11 versus four). Conflict of interest The authors declare that they have no conflict of interest.
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