Domestic violence in pregnancy: a systematic review of clinical guidelines

Domestic violence is a significant social and public health problem, which globally affects more than one-third of all women [1, 2]. The World Health Organization describes domestic violence as any violent and gender-based behavior causing damage or emotional, sexual, physical injury or distress for women [3]. Domestic violence and intimate partner violence that is perpetrated by a current or former partner are often used interchangeably in the literature [4]. The prevalence of domestic violence during pregnancy has been reported as high as 20% [5] and ranging from 15 to 71% in low and middle-income countries [6]. Estimations on rates of domestic violence in pregnancy amongst Iranian women vary significantly and range from 19.3 to 94.5% highlighting the extent of this problem [7]. Domestic violence has been associated with several adverse perinatal physical and mental health outcomes [8]. These perinatal effects include unplanned pregnancy, postponed entry to prenatal care, inadequate antenatal weight gain, several mental problems, miscarriage, vaginal bleeding, preeclampsia, preterm labor, dystocia, low birth weight infants, and postpartum depression [8‐11]. Prenatal care is a chance for healthcare providers to recognize abused pregnant women and support them with appropriate counselling and programs to protect the health of both mothers and infants [12, 13].

Clinical Practice Guidelines (CPGs) are a progressively common component of clinical care worldwide. Clinical practice guidelines have the potential to develop the care received by patients by improving interventions of proven benefit and reducing ineffective interventions [14]. Clinical practice guidelines are systematically standardized, and scientifically developed statements, designed to help practitioners in decision-making about appropriate health care for specific clinical conditions or health care issues [15]. Evidence-based clinical practice guidelines (EBCPGs) are developed through a systematic review of high-quality research to provide the best scientific evidence for healthcare recommendations [16]. These guidelines aim to promote patient outcomes by improving healthcare practice for certain medical conditions, standardizing care, reducing variations in practice, and minimizing morbidity and mortality. While EBCPGs are crucial for unifying practices and enhancing patient care, their development requires significant expertise, resources, and time [16]. In some cases, the costs of creating and implementing guidelines may exceed their benefits. For resource-limited settings, adapting existing high-quality guidelines may be a more efficient solution [14] similar to other settings [17]. The results of the preliminary review have shown that the existing clinical guidelines on violence during pregnancy related to universities and health centres in Toronto-Ontario [18], British Columbia [19], England [20‐26], Northern Ireland [27], and Queensland [28].

Considering the high prevalence of domestic violence during pregnancy in Iran and its adverse maternal and fetal consequences, it is necessary to provide a culturally based supportive care program to help these abused women. Although Integrated Maternal Health Care in Iran (a guide for midwives and general practitioners in the health care centres providing healthcare services before pregnancy and continues during the pregnancy and postpartum periods) is a valuable step toward improving maternal health, it cannot provide comprehensive and complete care for abused pregnant women [29]. According to the Integrated Maternal Health Care, pregnant women are screened for domestic violence at four stages: pre-pregnancy, the first trimester, the second trimester, and the third trimester. If no physical harm is detected, women are advised to communicate effectively and may be referred to a psychologist. In cases of maternal or fetal physical injury, vital signs are monitored, fetal heart rate is checked, injuries are treated, and immediate referral to a specialist is made [29]. The lack of a specific supportive care program and clinical guidelines for abused pregnant women, which is based on the economic, social, political, cultural, and religious situation of the country, demonstrates the necessity of developing such a program. Domestic violence during pregnancy is a widespread problem in many countries, and establishing effective and culturally sensitive clinical guidelines is essential to providing optimal care for abused pregnant women worldwide. In the process of designing the supportive care program for abused pregnant women and adapting the related guidelines, it is helpful to review the relevant clinical guidelines available in other countries. Therefore, the present study was designed to systematically review the existing clinical guidelines for domestic violence during pregnancy to explore insights for developing clinical guidelines in Iran and offering valuable instructions for healthcare systems worldwide.

This systematic review evaluates the quality of published clinical guidelines on domestic violence during pregnancy. It offers an overview of perinatal supportive care for abused pregnant women. The review includes international clinical guidelines to provide a global perspective. Fourteen guidelines were assessed in this systematic review. The results showed that the guideline development group was from seven high-income countries, and half were in the UK. The lack of guidelines from low and middle-income countries, and the cultural differences and different socio-economic statuses highlighted the importance of developing or adapting guidelines in these regions.

While the review highlights the importance of screening, identifying, and supporting women experiencing domestic violence [36, 37, 40, 42‐44], the interpretation of the findings suggests that there are significant gaps and inconsistencies in the existing guidelines.

One of the most important observations from this review is the variation in the methodological quality of the guidelines. While most clinical guidelines were of sufficient quality according to AGREE II ratings to be recommended [35‐43], none of the reviewed guidelines achieved high ratings across all six AGREE II domains. This suggests that while some guidelines offer valuable recommendations, there is a lack of comprehensive, high-quality frameworks that can be universally applied to effectively address domestic violence during pregnancy. For example, although privacy, screening, support, and documentation were commonly addressed, several key elements, such as the patterns of violence [37‐47] and the cycle of violence [35, 37‐48], were largely underrepresented. This inconsistency reflects an overall gap in providing healthcare providers with the adequate information necessary to fully understand the basis complexities of domestic violence as a global health issue.

Clinical guidelines need to include information about recognizing signs and symptoms of violence during pregnancy, as well as the risk factors associated with violence during pregnancy. This is crucial for identifying and supporting pregnant women who may be experiencing abuse or hidden violence during pregnancy but some of the reviewed guidelines had no recommendations about them [37, 43‐45]. This deficiency suggests that current guidelines may not fully equip healthcare professionals with the information necessary for early detection and intervention, particularly in settings where domestic violence is underreported. Furthermore, the result emphasizes the need for more practical training programs, particularly for midwives and other frontline healthcare professionals, to ensure they are equipped to handle the challenges of identifying and supporting women who are experiencing abuse.

The result of this study revealed that most of the reviewed guidelines explained the health consequences of violence during pregnancy [35‐39, 41, 45‐48]. Informing healthcare professionals about these consequences helps them to identify abused pregnant women and reduce the adverse effects of violence.

The most important part of reviewed clinical guidelines was the role of health care professionals. All of the guidelines had recommendations about privacy and confidentiality, screening, identification, support, and documentation. While these recommendations are crucial, they represent only the foundation of care. The last recommendations were about self-care and empowering [39, 41, 48], prevention [39, 41, 44, 48], medical care [36, 39, 41, 46], follow-up [39, 41, 43, 45], home visitation program [35, 39, 40, 43, 47], psychological counselling [35, 39, 41, 44, 46‐48] and barriers to screening [38‐42, 47, 48]. This highlights a significant area for improvement that guidelines should not only inform healthcare providers about recognizing violence but also about the broader systems of support that are necessary for long-term maternal and fetal well-being.

The reviewed guidelines noted the importance of training programs in improving the confidence and competency of health professionals in identifying and caring for women experiencing domestic violence. For successful screening, there should be a greater focus on training health professionals who conduct the screening; this may require comprehensive educational efforts, rather than just producing and distributing guidelines [43]. Training and support for midwives must be included to provide clinicians with the skills they need to identify and respond effectively to domestic violence. All of the guidelines except one [40] had recommendations on professional education and training. However, the training described often focuses on recognizing signs of violence and offering basic support, rather than equipping health providers with the comprehensive knowledge needed to address the complexity of domestic violence during pregnancy. Similarly, community awareness, and education programs, along with an appropriate response to domestic violence can play an important role in reducing violence, especially during pregnancy, but only two guidelines had recommendations for them [41, 48]. Community-based approaches, which are instrumental in reducing stigma and providing resources for at-risk individuals, should be incorporated into guideline frameworks, particularly in regions where domestic violence is prevalent but underreported.

The results showed that the guideline development group was from seven high-income countries, and half were in the UK. The study highlights a significant gap in the availability of domestic violence guidelines for pregnant women in low- and middle-income countries (LMICs), where the prevalence of domestic violence is high and healthcare infrastructure is often inadequate. While the absence of these guidelines is a significant concern, the study suggests that adapting existing guidelines, rather than creating new ones, could be more effective. The focus should not be on the urgent development of new frameworks, but on adapting and strengthening existing ones to suit the specific cultural, socio-economic, and healthcare contexts of LMICs. The study advocates for research and collaboration to develop contextually relevant, culturally sensitive guidelines, involving localized studies and engagement with local healthcare providers to address the needs of these populations effectively.

In conclusion, while the review offers valuable insights into the current state of clinical guidelines for domestic violence during pregnancy, it also highlights the need for critical improvements in both the content and implementation of these guidelines. Greater attention must be given to training, the provision of detailed, actionable information, and the contextualization of guidelines to ensure their relevance and effectiveness in diverse healthcare settings.

This is the first study that systematically reviewed guidelines in the field of domestic violence during pregnancy. The use of a standardized method and rating tool AGREE II was one of the strengths of the present study. Screening the title and abstract by one reviewer was the limitation of the study.

This study reviewed clinical guidelines for managing domestic violence during pregnancy, highlighting the essential role of healthcare professionals in identifying and supporting pregnant women affected by violence. Although many guidelines included recommendations on privacy, screening, and medical care, significant gaps remain, particularly in addressing the full range of healthcare needs—such as psychological counseling, prevention strategies, and follow-up support. Moreover, professional training and community education, which are critical for effective intervention, are insufficiently addressed in many guidelines.

The findings underscore the need for enhancing existing guidelines rather than creating entirely new ones. Efforts should focus on strengthening the current framework by incorporating more comprehensive recommendations on preventing violence, improving follow-up care, and addressing the barriers to screening. This is especially pertinent for low- and middle-income countries, where the burden of domestic violence during pregnancy is often under-recognized, and clinical guidelines are lacking. These countries should focus on adapting international guidelines to their specific contexts, ensuring that healthcare providers are equipped with the necessary knowledge and resources to support pregnant women experiencing domestic violence.