**5. Domestic violence as a child protection issue**

Domestic abuse during pregnancy has the potential to harm both a woman and her unborn child both physically and psychologically. This violence during pregnancy should be seen as a complex problem because of its dual risks to both a mother and her unborn child [102, 103, 104]. However, assessing domestic abuse as a child protection issue has been relatively slow in gaining health professional acceptance, even though the international evidence suggests that there is a clear and irrefutable link between domestic abuse and the co-occurrence of child abuse [105, 106, 107]. If a woman is being abused by a current or former partner, and she has other children living with her, the likelihood is that they are being abused too. Indeed, the situation where a woman and her children are both abused by the same male perpetrator is common [60]. The more severely a woman is harmed, the more severely her child is likely to be harmed [59].

Although pregnant women may experience domestic abuse in the same ways as women who are not pregnant, it has only been recently that attention has been paid to the intricacies of the relationship between pregnancy and child protection [44]. Evidence suggests that domestic abuse during pregnancy, and the first six months of child rearing, is significantly related to all three types of child maltreatment: child physical abuse, neglect, and emotional abuse, up to the child's fifth year, with children under one year being at the highest risk of injury, or death [108, 59]. In addition, where it is believed that a child is being abused; those involved with the child and the family should be alerted to the possibility of domestic abuse. An association of between 45-70% has been found between a father's violence to the mother and his violence to the children [59].

## **6. Co-occurrence of child and domestic abuse**

46 Child Abuse and Neglect – A Multidimensional Approach

weight and premature birth [101].

child is likely to be harmed [59].

mother and his violence to the children [59].

brain, foetal injury and even foetal death [57, 38, 39].

**5. Domestic violence as a child protection issue** 

irritability, contributing to the increased number of preterm births [97]. However, a causal link between domestic abuse during pregnancy and adverse perinatal outcomes has not been clearly demonstrated. These risks can be considerable as violence may increase rates of miscarriage, antepartum haemorrhage, premature birth, low birth weight, chorioamnionitis, placental damage, sexually transmitted infections, and effects on the developing infant's

The Domestic Violence, Crime and Victims Act (2004) [98] which was introduced to increase the protection, support and rights of victims and witnesses, has produced the biggest overhaul of domestic violence legislation for 30 years. The Act aims to ensure better protection for victims and bring more perpetrators to justice through civil and criminal law. Legally, according to this Act if a miscarriage is caused by abuse, the assailant can be charged under S.58 of the Offences against the Person Act, "using an instrument with intent to cause a miscarriage", and if a baby is born prematurely as a result of an assault, and then dies, the assailant may be charged with manslaughter [98]..One of the most consistent empirical findings, however, is the delay of antenatal care among victims of violence [99] which often results in inadequate care during pregnancy. Research indicates that many abused women only begin antenatal care in the third trimester [100], and this may be a serious risk factor for the foetus with the risk of pregnancy complications such as low birth

Domestic abuse during pregnancy has the potential to harm both a woman and her unborn child both physically and psychologically. This violence during pregnancy should be seen as a complex problem because of its dual risks to both a mother and her unborn child [102, 103, 104]. However, assessing domestic abuse as a child protection issue has been relatively slow in gaining health professional acceptance, even though the international evidence suggests that there is a clear and irrefutable link between domestic abuse and the co-occurrence of child abuse [105, 106, 107]. If a woman is being abused by a current or former partner, and she has other children living with her, the likelihood is that they are being abused too. Indeed, the situation where a woman and her children are both abused by the same male perpetrator is common [60]. The more severely a woman is harmed, the more severely her

Although pregnant women may experience domestic abuse in the same ways as women who are not pregnant, it has only been recently that attention has been paid to the intricacies of the relationship between pregnancy and child protection [44]. Evidence suggests that domestic abuse during pregnancy, and the first six months of child rearing, is significantly related to all three types of child maltreatment: child physical abuse, neglect, and emotional abuse, up to the child's fifth year, with children under one year being at the highest risk of injury, or death [108, 59]. In addition, where it is believed that a child is being abused; those involved with the child and the family should be alerted to the possibility of domestic abuse. An association of between 45-70% has been found between a father's violence to the Children in violent homes face three risks: the risk of observing traumatic events, the risk of being abused themselves, and the risk of being neglected [109]. There is strong evidence to indicate that child abuse and exposure to domestic abuse often co-occur [110, 111], and that a high proportion of infants and children living with domestic abuse are themselves being abused, either physically or sexually, by the same perpetrator [110, 5]. According to published studies, there is a 30 percent to 60 percent overlap between violence against children and violence against women in the same families and many child deaths occur in situations where domestic abuse is also occurring [11]. Although the studies on which these ranges are based employ different methodologies (e.g., definitions of child and domestic abuse, case record reviews, case studies, and national surveys), use different sample sizes, and examine different populations, they consistently report a significant level of cooccurrence [104] and point to the importance of protecting the abused parent to ensure the safety of the child.

Prolonged and/or regular exposure to domestic abuse can, despite the best efforts of the parents to protect the child, seriously affects an infant's development, health and emotional wellbeing in a number of ways. Although, system responses are primarily targeted towards adult victims of abuse, recently, increasing attention has been focused on children who witness domestic abuse, as studies estimate that between 10 and 20 percent of children are at risk for exposure to domestic abuse [111, 112]. A growing body of research suggests that children who live in a household where mothers are being abused by a partner are significantly affected, and experience considerable emotional and psychological distress [20, 113]. Living with or witnessing domestic abuse is identified as a source of "significant harm" for children by the Adoption and Children Act (2004). In the US child abuse and maltreatment have been reported to be a risk marker of domestic violence with each year seeing an estimated 3.3 million children exposed to family violence and abuse [114]. There is also evidence to suggest that in 75-90% of cases, children are in the same or next room when their mother is being abused [115]. Indeed, Mullender et al [113,116] goes as far as saying that in 90 per cent of incidents, infants and children are witnesses to the violence. Infants may be greatly distressed by witnessing the physical and emotional suffering of a parent [19, 104, 116], which can in itself, be psychologically and emotionally harming. This can result in infants becoming more fearful, anxious, and depressed, having temper tantrums, sleep disturbances, and consistently crying, and having extreme difficulties in nurseries and play school [19].

### **7. The role of healthcare professionals**

For some time health care and primary care professionals such as midwives, health visitors, obstetricians, general practitioners and paediatricians have been acknowledged as having a key role in child protection and family violence [117, 118]. They may be the first to detect that a child is at risk, and the consequences of them failing in this recognition can be dire. However, until recently the UK National Health Service (NHS) has largely ignored the

problem of identifying women who access health services for injuries caused by domestic abuse, while historically primary care health professionals have experienced difficulties when attempting to identify an abused child [119, 57]. There are now many clear messages from Government, professional organizations and research to indicate that health professionals, such as midwives, should be actively involved in tackling these significant public health and primary care issues [120, 121]. Historically, midwives have experienced certain difficulties when attempting to identify either or both domestic and child abuse [122]. These difficulties have led to low detection rates that are attributed to: midwives' attitudes towards victims of abuse [119, 123]; their general lack of knowledge, education and training; and a lack of understanding of their perceived professional role in addressing both forms of abuse [124, 125]. Furthermore, in a review of fatal child abuse cases by the Department of Health by Sinclair and Bullock [126] it was found that health professionals were more likely than any other group to have knowledge of the child, and over a quarter of children who died at the hands of their parents were unknown to social services. Also a NSPCC publication, "What Really Happened?" [127] highlights how many infant deaths and serious injuries could be prevented if all professionals within primary care were better informed and equipped to identify family abuse. Although research in this area is increasing, it is often difficult to determine the exact nature of the pregnancy-related violence and this is posing difficulties for both practitioners and researchers, who need a clear understanding of the relationship between domestic and child abuse and pregnancy in order to develop risk assessment and screening tools and effective prevention and intervention programmes. Worryingly, although abuse may begin or accelerate during pregnancy few women report the problem to their primary care providers [125].

Recognizing the Co-Occurrence of Child and Domestic Abuse in Pregnancy and the First Postnatal Year 49

To assess and intervene appropriately to situations where domestic or child abuse are known or suspected, midwives, managers and supervisors must have a willingness to identify and report the abuse. They need to have had opportunities to undertake up-to-date education and training and skills necessary to ask questions, and to offer the appropriate multi-professional help and inter-agency support required [131] well as an understanding of domestic violence risk assessment and safety planning in child protection [132]. In addition, regular continual professional development updates should be available for all. The Department of Health 2006 publication Domestic violence: a resource manual for health care professionals [133] supports the need for education and training of health professionals, as

the majority of women will use the health care system at some stage in their lives.

woman seeking help [128].

sufficient privacy are frequently cited.

The most important factor in identifying domestic and child abuse is the awareness that it often commences or escalates during pregnancy. There are a number of physiological, psychological, emotional and behavioural indicators which can alert a midwife and other health professionals to the possibility of potential or actual abuse. Where abuse is suspected, the midwife has a duty of care to routinely ask the woman about problems with relationships, but only when it is safe to do so, i.e. not when a partner or other person is present. The midwife must not put the woman or her/himself at any further risk. The questioning must be undertaken very sensitively and very carefully. The midwife's role and responsibility is then to provide the appropriate response, believing the woman, showing her that someone cares, not judging her, respecting her reasons and decisions to stay or leave the relationship, offering her support, providing her with helpful information, referring her to appropriate agencies, or any other action that may be required [130]. All midwives should be aware of the services and resources [statutory, community and voluntary] available both locally and nationally to a woman and children suffering domestic abuse. Maternity services should be active in developing a multi-agency, interdisciplinary approach in local procedures and services, to ensure a seamless and effective response to a

It must also be remembered that victims of domestic abuse may also be reluctant to disclose abuse for a variety of reasons which include: reprisals from their partner; an outsider becoming involved; embarrassment; and importantly fear of losing their children if social services become involved. Research, however, has shown that often these women hope that someone will realise that something is wrong and ask them about it [38,130]. Many women may not spontaneously disclose the issues of child or domestic abuse in their lives, but often respond honestly to a sensitively asked question [38]. For midwives routinely to ask women about domestic abuse and to offer support and information is therefore an extremely important issue in both community and primary care settings. However, although midwives approve in theory of routine questioning about domestic violence, and also broadly agree that it is their responsibility; in practice, only about two-thirds are happy to do it [134]. It appears that routine enquiry about domestic violence during antenatal booking is infrequent despite such enquiry being included in clinical practice recommendations and is made less frequently than any other aspect of social history taking [135]. Practical and personal difficulties, including lack of time, staff shortages, and difficulty in obtaining

## **8. Midwives response to domestic and child abuse in pregnancy**

The provision of care to families where issues of possible, or actual child maltreatment have been raised is now seen as one of the most difficult and challenging areas of contemporary maternity practice [128, 129]. Community midwives have always had a role in primary care; however, there is now an explicit need for the profession to direct its attention to issues such as domestic abuse. Even though evidence suggests that 35% of women already suffering domestic abuse experience an increase during pregnancy, and the postpartum, they are rarely identified by midwives [123,125). Midwives have experienced certain difficulties when attempting to identify, either, or both, domestic and child abuse [125], and this finding may represent a reluctance by midwives to discuss the topic of violence with their clients, arising in many cases, from fears and anxieties about causing offence; revealing something which may escalate out of control; of not knowing what to do if abuse is disclosed; of embarrassment; or at a personal level identification with abuse either as a victim or perpetrator [38]. However, this reluctance may also correspond in general to: midwives' attitudes towards victims of abuse [123]; their general lack of knowledge, education and training and available information about questioning and screening protocols [130, 125); and a lack of understanding of their perceived professional role in addressing both forms of abuse [124, 125]. Importantly, at a more basic level the opportunity to 'ask the question' may not always be available i.e. a partner or other family member may be present [130].

To assess and intervene appropriately to situations where domestic or child abuse are known or suspected, midwives, managers and supervisors must have a willingness to identify and report the abuse. They need to have had opportunities to undertake up-to-date education and training and skills necessary to ask questions, and to offer the appropriate multi-professional help and inter-agency support required [131] well as an understanding of domestic violence risk assessment and safety planning in child protection [132]. In addition, regular continual professional development updates should be available for all. The Department of Health 2006 publication Domestic violence: a resource manual for health care professionals [133] supports the need for education and training of health professionals, as the majority of women will use the health care system at some stage in their lives.

48 Child Abuse and Neglect – A Multidimensional Approach

problem of identifying women who access health services for injuries caused by domestic abuse, while historically primary care health professionals have experienced difficulties when attempting to identify an abused child [119, 57]. There are now many clear messages from Government, professional organizations and research to indicate that health professionals, such as midwives, should be actively involved in tackling these significant public health and primary care issues [120, 121]. Historically, midwives have experienced certain difficulties when attempting to identify either or both domestic and child abuse [122]. These difficulties have led to low detection rates that are attributed to: midwives' attitudes towards victims of abuse [119, 123]; their general lack of knowledge, education and training; and a lack of understanding of their perceived professional role in addressing both forms of abuse [124, 125]. Furthermore, in a review of fatal child abuse cases by the Department of Health by Sinclair and Bullock [126] it was found that health professionals were more likely than any other group to have knowledge of the child, and over a quarter of children who died at the hands of their parents were unknown to social services. Also a NSPCC publication, "What Really Happened?" [127] highlights how many infant deaths and serious injuries could be prevented if all professionals within primary care were better informed and equipped to identify family abuse. Although research in this area is increasing, it is often difficult to determine the exact nature of the pregnancy-related violence and this is posing difficulties for both practitioners and researchers, who need a clear understanding of the relationship between domestic and child abuse and pregnancy in order to develop risk assessment and screening tools and effective prevention and intervention programmes. Worryingly, although abuse may begin or accelerate during

pregnancy few women report the problem to their primary care providers [125].

**8. Midwives response to domestic and child abuse in pregnancy** 

not always be available i.e. a partner or other family member may be present [130].

The provision of care to families where issues of possible, or actual child maltreatment have been raised is now seen as one of the most difficult and challenging areas of contemporary maternity practice [128, 129]. Community midwives have always had a role in primary care; however, there is now an explicit need for the profession to direct its attention to issues such as domestic abuse. Even though evidence suggests that 35% of women already suffering domestic abuse experience an increase during pregnancy, and the postpartum, they are rarely identified by midwives [123,125). Midwives have experienced certain difficulties when attempting to identify, either, or both, domestic and child abuse [125], and this finding may represent a reluctance by midwives to discuss the topic of violence with their clients, arising in many cases, from fears and anxieties about causing offence; revealing something which may escalate out of control; of not knowing what to do if abuse is disclosed; of embarrassment; or at a personal level identification with abuse either as a victim or perpetrator [38]. However, this reluctance may also correspond in general to: midwives' attitudes towards victims of abuse [123]; their general lack of knowledge, education and training and available information about questioning and screening protocols [130, 125); and a lack of understanding of their perceived professional role in addressing both forms of abuse [124, 125]. Importantly, at a more basic level the opportunity to 'ask the question' may The most important factor in identifying domestic and child abuse is the awareness that it often commences or escalates during pregnancy. There are a number of physiological, psychological, emotional and behavioural indicators which can alert a midwife and other health professionals to the possibility of potential or actual abuse. Where abuse is suspected, the midwife has a duty of care to routinely ask the woman about problems with relationships, but only when it is safe to do so, i.e. not when a partner or other person is present. The midwife must not put the woman or her/himself at any further risk. The questioning must be undertaken very sensitively and very carefully. The midwife's role and responsibility is then to provide the appropriate response, believing the woman, showing her that someone cares, not judging her, respecting her reasons and decisions to stay or leave the relationship, offering her support, providing her with helpful information, referring her to appropriate agencies, or any other action that may be required [130]. All midwives should be aware of the services and resources [statutory, community and voluntary] available both locally and nationally to a woman and children suffering domestic abuse. Maternity services should be active in developing a multi-agency, interdisciplinary approach in local procedures and services, to ensure a seamless and effective response to a woman seeking help [128].

It must also be remembered that victims of domestic abuse may also be reluctant to disclose abuse for a variety of reasons which include: reprisals from their partner; an outsider becoming involved; embarrassment; and importantly fear of losing their children if social services become involved. Research, however, has shown that often these women hope that someone will realise that something is wrong and ask them about it [38,130]. Many women may not spontaneously disclose the issues of child or domestic abuse in their lives, but often respond honestly to a sensitively asked question [38]. For midwives routinely to ask women about domestic abuse and to offer support and information is therefore an extremely important issue in both community and primary care settings. However, although midwives approve in theory of routine questioning about domestic violence, and also broadly agree that it is their responsibility; in practice, only about two-thirds are happy to do it [134]. It appears that routine enquiry about domestic violence during antenatal booking is infrequent despite such enquiry being included in clinical practice recommendations and is made less frequently than any other aspect of social history taking [135]. Practical and personal difficulties, including lack of time, staff shortages, and difficulty in obtaining sufficient privacy are frequently cited.

## **9. Midwifery settings – Differences in community and hospital-based**

Recognizing the Co-Occurrence of Child and Domestic Abuse in Pregnancy and the First Postnatal Year 51

Research and experience indicate that very young babies are extremely vulnerable to abuse and that work carried out in the antenatal period to assess risk and plan intervention will help to minimise harm. Any concerns about the welfare of an unborn baby, or about the future care of the baby when born should be shared with the appropriate agency at the earliest opportunity, as plans for safeguarding may need to be put in place before the baby is born. Antenatal risk assessment is a valuable opportunity to develop a pro-active multiagency approach to families where there is an identified risk of harm. The aim is to provide support for families, to identify and protect vulnerable children and to plan effective care programmes; recognising the long-term benefits of early intervention for the welfare of the child. The UK Local Safeguarding Children Board (LSCB) have produced a set of procedures that explain the action any person should take when they think a child needs protecting because they may have been abused, or are at risk of abuse or significant harm [132]. They also take into account any risk to the unborn child. They clarify the responsibility of the various agencies involved, for reporting and investigating allegations of abuse. However, the process of assessment is consistently criticized in inquiries particularly in relations to professionals' understanding of risk factors (Brandon et al. 1999). In assessing risk there is

Globally health services including maternity services play an important role in safeguarding children. Within the UK health care professionals ensure that children and families receive the care, support and treatment they need in order to promote children's health and development. Staff such as midwives, health visitors, obstetricians, general practitioners (GPs), and other staff who work as members of the primary care, or hospital maternity team have a safeguarding role to play in the identification of babies and children who have been abused, those who are at risk of abuse, and in subsequent intervention and protection services. In the UK we expect that every pregnant woman will have access to, and engage with, high quality maternity services. It is also increasingly acknowledged that for the majority of women, pregnancy and childbirth are normal life events and that care of these women and their babies may be undertaken exclusively through midwifery-led services. The universal nature of health provision means that maternity professionals such as midwives and obstetricians are often the first to be aware that families are experiencing difficulties. All health care organisations have a duty under the Children Act 2004 to make arrangements to safeguard and promote the welfare of children and young people. Every Child Matters marked a shift of focus from child protection to improving and promoting the

health and wellbeing of all children and incorporates several important themes.

However the evidence suggests that domestic abuse is a damaging social problem affecting the health of many women and children within pregnancy and the first postpartum year. It cannot be solved by one profession alone; however, the professional's role in identification and referral plays a critical part in primary care co-ordinated response. In order for such a

**10. Multi-agency pre-birth child protection procedures** 

sometimes a tendency to overlook the mother's male partner.

**11. Conclusion** 

Findings from research show that significantly fewer midwives in hospital settings are addressing the issue of domestic abuse with their clients, as they appear to be driven by more medically dominant organizational structures and targets, which result in them using a more standardized form of care that stresses measures of efficiency, effectiveness and risk management [125]. According to this study hospital midwives work in a setting that has an ideology which places less emphasis on the psychosocial needs of the individual woman and her child and more on providing care for women experiencing complications, and thus public health issues are seen as low priorities. These findings are consistent with work by Hunter [136] whose results suggest that the occupational ideology of the hospital midwife is 'with the institution' rather than with a more 'woman-centred' approach. On the other hand, more midwives from community-based settings appear to follow more women-centred and child-focused care.

Firstly, community midwives are able to create a healthy living environment for women experiencing domestic violence, by asking about 'abuse' with their clients [137]. Secondly, they integrate health promotion and health empowerment into the primary care setting by working in partnership with the woman in their own homes, frequently talking to them about issues such as domestic and child abuse, and are more aware of providing private facilities in which woman can discuss violent relationships. Thirdly, they develop links with other settings and with the wider community [138]. Community, midwives are more empowered to use a joined-up approach that includes an understanding of evidence-based research in the area, a clear knowledge of local and national multi-professional support agencies, and inter-agency networks and refuges that allows them to give on-going and appropriate information that in itself can empower women to make their own informed choices about how to deal with abuse [125]. The Code of Professional Conduct exhorts midwives to work collaboratively, to enable them to strengthen areas of practice by liaising with other professionals and learning from them [139].

However, the biggest hindrance recorded for both hospital and community midwives is the reluctance of a partner to leave the consultation. Recent changes in midwifery practice designed to 'empower women' and demedicalize childbirth may in reality be reducing the possibility of effective intervention i.e. the traditional concept of women-only space is rapidly disappearing as more and more men are now accompanying their partners to their antenatal and postnatal visits. Women now hold their own notes, eliminating confidential documentation of suspicions of/or identified cases of domestic violence. This can lead women themselves to feel emotionally unable to, or physically prevented from, accessing support, either from their family and friends, or from statutory and voluntary agencies. International research evidence illustrates that maternity services are no longer woman-only spaces because women are now accompanied by their partners when attending antenatal clinics, and partners are often present in primary care appointments [128, 130].
