Domestic violence and pregnancy : impact on outcome and midwives' awareness of the topic

Abstract: Objective: The overall aim of this thesis was to investigate whether selfreported history of violence is associated with increased risk of labour dystocia in nulliparous women at term and to elucidate midwives’ awareness of domestic violence during pregnancy in southern Sweden. Design/Method/Setting/Population: Paper I utilised a population-based multi-centre cohort study design. A self-administrated questionnaire was administered at four points in time with start at 37 weeks of gestation, at nine obstetric departments in Denmark. The total cohort comprised 2652 nulliparous women, among whom 985 (37.1%) met the protocol criteria for labour dystocia. In paper II an inductive qualitative design was utilised, based on focus group interviews. Participants were midwives with experience of working in antenatal care units connected to two university hospitals in southern Sweden. Sixteen midwives were recruited by network sampling complemented by purposive sampling, and were divided into four focus groups of 3 to 5 individuals. Results: In paper I cohort of the total, 940 (35.4 %) women reported experience of violence and of these 66 (2.5 %) women reported exposure of violence during their first pregnancy. Further, 39.5% (n = 26) of those had never been exposed to violence before. Univariate logistic regression analysis showed no association between history of violence or experienced violence during pregnancy and labour dystocia at term, crude OR 0.91, 95% CI (0.77-1.08), OR 0.90, 95% CI (0.54-1.50), respectively. However, violence exposed women consuming alcoholic beverages during late pregnancy had increased odds of labour dystocia (crude OR 1.49, CI: 1.07 – 2.07) compared to unexposed to violence women who were alcohol consumers (crude OR 0.89, 95 % CI: 0.69- 1.14). In paper II five categories emerged: 1) ‘Knowledge about ‘the different faces’ of violence’, perpetrator and survivor behaviour, and violence-related consequences. 2) ‘Identified and visible vulnerable groups’, ‘at risk’ groups for exposure to domestic violence during pregnancy, e.g. immigrants and substance users. 3) ‘Barriers towards asking the right questions’, the midwife herself as an obstacle, lack of knowledge among midwives as to how to handle disclosure of violence, and presence of the father-to-be at visits to the midwife. 4) ‘Handling the delicate situation’, e.g. the potential conflict between the midwife’s professional obligation to protect the abused woman and the unborn baby and the survivor’s wish to avoid interference. 5) ‘The crucial role of the midwife’, insufficient or non-existent support, lack of guidelines and/or written plans of action in situations when domestic violence is disclosed. The above five categories were subsumed under the overarching category ‘Failing both mother and the unborn baby’ which highlights the vulnerability of the unborn baby and the need to provide protection for the unborn baby by means of adequate care to the pregnant woman. Conclusions: Our findings indicate that nulliparous women who have a history of violence or experienced violence during pregnancy do not appear to have a higher risk of labour dystocia at term, according to the definition of labour dystocia used in this study. Additional research on this topic would be beneficial, including further evaluation of the criteria for labour dystocia (Paper I). Avoidance of questions concerning the experience of violence during pregnancy may be regarded as a failing not only to the pregnant woman but also to the unprotected and unborn baby. Nevertheless, certain hindrances must be overcome before the implementation of routine enquiry concerning pregnant women’s experiences of violence. It is of importance to develop guidelines and a plan of action for all health care personnel at antenatal clinics as well as continuous education and professional support for midwives in southern Sweden (Paper II).