The pregnancy police
Telling midwives to quiz pregnant women about domestic violence is an abuse of their position of trust.
The UK public health minister Melanie Johnson recently announced that midwives will routinely ask pregnant women whether they are at risk of domestic violence. An advisory group will be established to help midwives ask discreet questions, so that appropriate advice can be offered and help given when needed.
This announcement found favour with the UK Home Office and the Department of Health, as well as midwifery leaders and Women’s Aid. And according to the minister, women themselves didn’t mind being questioned by these caring and sensitive health professionals.
The Department of Health website reports that it has funded a pilot project that demonstrates the success of these methods, undertaken by the University of the West of England and Bristol NHS Trust (this is in fact North Bristol NHS Trust). ‘Positive evaluation of the project provides a strong evidence base to begin the introduction of a national programme to develop the consistent use of routine enquiry and the provision of information across all health professionals.’ (1)
However, North Bristol’s briefing of its pregnancy and domestic violence programme suggests that no such evidence exists. It says: ‘Given the lack of a non-intervention comparison group, the relatively small numbers undertaking the training and low response rate to some questions, this evaluation may be best viewed as a feasibility study.’ (2) It goes on to suggest that future studies could include a comparison group of midwives not undertaking training, examination of different geographical regions, and a comparative analysis of the outcomes for women based on differing models of questioning.
Irrespective of the evidence, as a nurse and former midwife I am very concerned about this development. It seems to represent yet another justification for intrusion by health professionals into the private lives of families, exploiting the trusting relationship that generally exists between health professionals and patients. It will not do women or midwives any favours, but is likely to introduce suspicion and mistrust between health workers and pregnant women, and between pregnant women and their partners.
The Royal College of Midwives has been angling for this extension to the role of midwives for some time now. In 1997, it published a position paper called ‘Domestic Abuse in Pregnancy’, giving guidance on the physical, emotional and behavioural signs of abuse, and the steps midwives needed to take when they suspected abuse. The government immediately gave the initiative its full backing, and the then health secretary Frank Dobson launched the paper in a photocall at the House of Commons.
Domestic violence is now seen as one of the key issues for public officials – given added urgency by the reported close links to child protection. There is a prevalent view that women are more prone to domestic violence during pregnancy or in the first year after birth. However, reports are frequently exaggerated, and figures are backed up with crime statistics that are based on a redefinition of abuse.
Abuse is no longer just assumed to be physical, but can now be psychological or economic. Verbal abuse or even verbal disputes can now be termed domestic violence, presumably because ‘words hurt’ and ‘one thing leads to another’. In 1999 Home Office research found that one in four women had suffered from ‘some form of violence’ at the hands of her partner, but this included a broad range of incidents. The most common kind of assault included in the study was ‘pushing, shoving and grabbing’. Forty-one per cent of victims were injured, and this injury was in most cases restricted to bruising. Indeed, only 17 per cent of incidents recorded in the survey were considered to be crimes by their victims, while only a third of women victims agreed that their experience made them ‘a victim of domestic violence’ (3).
Other studies used even broader definitions of ‘domestic violence’, including ’emotional and financial abuse’, such as forcing partners to do domestic tasks or to give them money. These statistics blur the distinction between ‘grabbing’ and violent assault. Now we are told that the three risk factors for domestic abuse are: being a woman, being pregnant, and being between the ages of 16 and 24.
Midwives are uniquely accepted and welcomed into the lives of pregnant women at a very special time. They are viewed not only as professional healthcare workers, but also as confidants and problem solvers – midwives are trusted, and confidence is expected from them in return. Is it not an abuse of that trust if midwives’ agenda is now seen to include searching out recipients of domestic abuse and documenting it? Questions and answers can be misunderstood – but once midwives have identified a ‘cause for concern’ they will be obliged to report it, and the official wheels will begin to roll.
Melanie Johnson also advised that ‘domestic violence often starts or escalates during pregnancy and is associated with increases in rates of miscarriage, low birth weight, premature birth, fetal injury and fetal death makes for stark reading’. Pregnant women get used to being asked questions about every aspect of their personal lives, but generally accept them in the interest of their own and their baby’s health. Presenting with an unfortunate history of miscarriage, however, should be an indication of the need for sympathy and support from the midwife – not an opportunity to pry, no matter how tactfully or carefully.
In Bristol’s Pregnancy and Domestic Violence Programme, midwives reported the presence of a family member, in particular a male partner, to be the most significant barrier to enquiring about domestic abuse. If we are told that one woman in four has been abused, it would be logical to assume that many of their male partners are abusers. Is the midwife supposed to consider a male partner guilty until she’s had an opportunity to question the woman alone? Not surprisingly, one perceived barrier to the midwives in the programme enquiring about abuse was professional risk – the potential threat of violence towards them.
The midwife may want to help what she sees as a vulnerable woman. But her perspective is not the same as the woman’s, and they should not be conflated or confused. The woman may not want ‘help’ from midwives or other public officials, and the woman’s wishes should be respected.
The promotion of this role for midwives could be detrimental to the health of the pregnant women and their babies. If women feel that their every word, symptom,
or bruise is being screened for evidence of domestic abuse, the barriers are likely to go up. If midwives jump in and act on confessions, pregnant women are likely to clam up, become reticent about confiding in them or even leave antenatal care.
Policing pregnant women is not part of midwives’ brief. They should stick to the job they are trained to do and for which they have fought long and hard to gain acceptance – that of delivering a professional and supportive midwifery service. It would be a shame if the perceived gains of pregnancy care are lost in the course of midwives inadvertently acting as an extension of the police.
Promoting woolly definitions of abuse trivialises the experience of women who do suffer from serious abuse. And once a sarcastic comment is equated with a physical beating, women suffering from real violence may be less likely to be identified and provided with the support that they need.
Women can feel vulnerable and even frightened when pregnant, and they need to know that their midwife is supportive and trusting. The last thing needed is for a woman’s confidences to be taken down and used in evidence against her. Women are quite capable of asking for help if they need it.
Brid Hehir is the lead for patient and public involvement at Camden Primary Care Trust, London.
(1) Publications and statistics, on the Department of Health website
(2) North Bristol National Health Service Trust website
(3) Domestic Violence: Findings from a New British Crime Survey Self-Completion Questionnaire, Catriona Mirrlees-Black, Home Office Research Study, 1999
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