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

3

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

4

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.

5

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

7

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.

8

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,

9

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.

10

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

11

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

12

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

13

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,

14

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

15

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

16

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

17

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,

18

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

19

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

24

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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