Midwives’ experiences of routine antenatal questioning relating to men's violence against women

Summary

Objective

to describe and use the experience gained by antenatal-care midwives who routinely questioned pregnant women about personally experienced violence.

Design

qualitative, using focus-group discussions.

Setting

antenatal care in a city in south-central Sweden.

Study population

21 midwives.

Data collection and analysis

the midwives participated in any one of five focus-group discussions held by the same moderator and observer. The discussions were audiotaped, transcribed verbatim and analysed using qualitative content analysis.

Findings

the importance of routine questioning about violence was emphasised in all groups. Midwives felt they had failed in their duty when women were not questioned. The two main obstacles to such questioning were the delicacy of the subject and the routine of inviting the partner to all visits. The perceived delicacy underlined the need to devise a natural setting for the questioning. The midwives wanted to connect questions about abuse with related subjects routinely established in early pregnancy. As the partner was invited to every visit, it was not practicable to establish a procedure whereby the assessment was connected with a particular visit. Other obstacles included the following: time constraints, oversight, a preconceived notion of who might be a victim of abuse and language difficulties. The midwives emphasised the importance of training, easy access to support for abused women, and personal counselling for midwives. They described their role as raising awareness of the problem of male violence, reducing the shame of being abused, informing, giving emotional support and mediating help.

Key conclusions and implications for practice

in order to ensure that the establishment of experience of violence is a routine enquiry in antenatal care, midwives must have a reasonable opportunity of carrying out such questioning. A routine that offers each woman a private consultation will ease the questioning and save time and distress.

Introduction

Men's violence against women has a profound effect on women's health and well-being (Sutherland et al., 1998; Campbell et al., 2002; Krug et al., 2002). Such violence is recognised as a serious public health issue, and should consequently be a major concern in health care. In prevalence studies on national samples, about 10–34% of women are reported as having been physically assaulted by their present or former male partner some time in their life (Krug et al., 2002). Prevalence reports of physical violence during pregnancy range from 0.9–20.1% (Gazmararian et al., 1996; Hedin et al., 1999; Stenson et al., 2001a; Bacchus et al., 2004).

Most victims of male violence are themselves reluctant to raise the issue of abuse (Plichta et al., 1996; McNutt et al., 1999). Many professional health-care organisations recommend routine enquiry into subjection to violence (Jones and Horan 1997; Paluzzi et al., 2000; Marchant et al., 2001). Others claim that there is insufficient evidence to support the acceptability and effectiveness of such a routine (Ramsay et al., 2002; US Task Force, 2004). Studies on women in antenatal care show that most pregnant women regard questions about abuse as acceptable (Stenson et al., 2001b; Webster et al., 2001; Bacchus et al., 2002), that routine questioning helps to identify women who are the victims of violent behaviour (Covington et al., 1997; Wiist and McFarlane, 1999), and that intervention to prevent further abuse or to increase abused women's safety response can be successful (McFarlane et al., 1998; Parker et al., 1999; McFarlane et al., 2000). McFarlane et al. (2000) concluded that abuse screening itself may be the most effective form of intervention to prevent violence against pregnant women. However, evaluation of treatment is a cumbersome procedure. Randomised-controlled trials (i.e. assignment to intervention or control) have been requested (Ramsay et al., 2002; US Task Force, 2004). As the questioning itself might constitute an intervention, there will be no unaffected abused women for control purposes. Assignment to non-treatment is also unacceptable for ethical reasons (Parker et al., 1999). Furthermore, routine questioning has been criticised, as it does not fulfil accepted principles for screening programmes (Garcia-Moreno, 2002; Ramsay et al., 2002). ‘Screening’ is a scientific and biomedical term that is inappropriate for routine antenatal questioning about abuse (Bradley et al., 2002; Taft, 2002). In antenatal care, such questioning is included to detect somatic and psychosocial risks to the mother and her fetus.

Antenatal care offers opportunities for health-care workers to interact with and assist abused women. Despite recommendations for routine enquiry about experiences of violence, most women are never asked (Horan et al., 1998; Durant et al., 2000; Foy et al., 2000; Marchant et al., 2001). Numerous obstacles preventing health-care staff from dealing with men's violence against women have been identified (Sugg and Inui, 1992; Rönnberg and Hammarström, 2000; Waalen et al., 2000; Mezey et al., 2003). Difficulties perceived by midwives were, for example, lack of knowledge or time, too little confidential time with the woman due mainly to the presence of her partner, absence of guidelines by managers, lack of assessment routines and intervention plans, and lack of support for midwives (Scobie and McGuire, 1999; Edin and Högberg, 2002; Mezey et al., 2003; Protheroe et al., 2004). Midwives’ own experience of violence, safety issues and concern about confidentiality were also brought up as hindrances. According to ethical recommendations from the World Health Organization (WHO) about research into violence against women, steps should be taken to enhance participants’ safety and reduce any possible distress to participants and interviewers caused by such questioning (WHO, 1999). This is also important when research is put into practice. For the woman's safety, questioning must be carried out in privacy, and demands on staff should not cause unnecessary strain. Tactics facilitating routine questioning about violence include an official policy for identifying and assisting women exposed to violence, printed material displayed in waiting rooms, specific questions posed to all pregnant women and easy access to appropriate referral (Wiist and McFarlane, 1999; Waalen et al., 2000; McCaw et al., 2001).

During 1997 and 1998, physical and sexual abuse was studied at all antenatal-care units in one Swedish municipality (Stenson et al., 2001a, Stenson et al., 2003). In January 2001, as a result of these studies, the managers of the antenatal-care service in the actual county introduced questions about emotional, physical and sexual abuse as part of the regular psychosocial assessment.

Within the Swedish health service, all pregnant women have equal access to antenatal care, and virtually every pregnant woman visits her clinic regularly. The service is free of charge and available nation-wide. The National Board of Health and Welfare issues national regulations and guidelines for antenatal care. Questioning for psychosocial and physical risk factors is standardised but does not include routine questioning about violence. The guidelines may be interpreted and adapted locally. Routine care comprises eight to 10 visits during pregnancy and one postpartum visit, usually to the same midwife. Home visits are not part of routine care. An obstetrician or a primary-care physician is called in if the midwife considers it necessary. Furthermore, considerable effort is made in antenatal care to involve male partners in their wives’ pregnancy and childbirth, and subsequently in childcare. They are encouraged to accompany their spouse on visits to the antenatal clinic, and are invited to antenatal classes.

Available research was taken into account when the programme was designed. Before routine questioning was introduced, midwives at the antenatal clinics had received at least one day's education about men's violence against women. Standardised questions (Box 1) about current and past subjection to emotional, physical, and sexual violence were included as a component of the regular psychosocial assessment of all pregnant women who registered at antenatal clinics in the region. The questions were derived from the Abuse Assessment Screen (Parker and McFarlane, 1991). Women visiting the clinics for contraceptive counselling were assessed as well, but that is not in the remit of this study. Official policy and instructions about questioning, documentation and referral were established. Printed laminated cards displaying the questions and key telephone numbers for referral were distributed to all midwives. According to the instructions, the questioning was to be carried out in privacy twice during pregnancy and again after birth. The clinics were supplied with information about the assessment, intended for display in waiting rooms. They were also supplied with wallet-sized cards with information about resources for abused women. It was intended that a resource card should be given to each registered woman, and also be placed in women's toilets. At the start of the programme, a midwife with special knowledge of the subject provided training, including ways of questioning and how to intervene when a woman revealed abuse and requested help. To reinforce compliance, and to allow for staff turnover, repeated training, seminars, case discussions and coaching have been arranged at the antenatal clinics, and they have been supplied with literature on the subject. A midwife trained in antenatal care, and with knowledge of men's violence against women, has always been available on the telephone to support the antenatal midwives.

The present study was undertaken to describe and use the experience gained by antenatal-care midwives who had routinely questioned pregnant women about men's violence against women. The intention was to describe their thoughts and feelings about the task, persisting obstacles and possible solutions and aids in routine questioning.