September 2002 Vol 29,3

Sheila Kitzinger's Letter from Europe

Silence is Collusion

There is little social acknowledgement of violence against women in pregnancy – misnomered "domestic" violence. It is, almost without exception, male violence. Caregivers often prefer not to see it and have no idea of what action to take if they do. To talk to women about it would be embarrassing and intrude on a couple’s relationship, which is a matter for them alone. Though doctors, nurses and midwives tackle subjects like sexually transmitted diseases, fetal abnormalities, miscarriage, pre-term birth and perinatal mortality rates, this is the last taboo.

Internationally, statistics reveal that one in four women suffers "domestic" violence at some time in her life.¹ Home Office figures in Britain show that every three days a woman is killed by her partner or ex-partner.² In pregnancy violence is more common than conditions for which women are routinely screened, such as pregnancy-induced hypertension and diabetes.³

Much of the violence against pregnant women and new mothers involves sexual abuse. In an interview the formerly feminist novelist Fay Weldon was asked why she stated that rape was not among the worst crimes. She replied, "After all, it’s only a penis."⁴ This ignores the context in which forced penetration occurs. I wonder what the woman whose partner tore out her episiotomy sutures in order to rape her would have thought about that. Trivialising rape means ignoring bite marks, the knife, the rope, the broken glass, hands that choke, and the tyranny of uncontrolled power.

The Intra-Parliamentary Group on Maternity, under the aegis of the National Childbirth Trust with the Royal College of Midwives, the Royal College of Obstetricians and various childbirth organisations, meets regularly in the House of Commons, and is attended by politicians of all parties. Working together, we succeed in drawing attention to the alarming increase in the rate of Cesarean sections and other obstetric interventions and stimulated research into how to increase the proportion of normal births by ensuring that every woman is cared for by a midwife who knows how to support physiological birth. Meetings direct attention to political issues in birth that need to be dealt with at a parliamentary level. As a result questions are asked in the House, investigative committees set up, legislative changes made, and public policy developed.

After Labour came to power in Britain, the National Health Service established a group to review murders in which domestic violence is a factor. It laid down policy and procedure guidelines. This followed the 1998 publication of the report "Why Mothers Die – A Confidential Enquiry into Maternal Deaths", which, for the first time, included deaths from violence.⁵ A task group was set up and four day multi-agency training courses started, with caregivers in many different fields, and peer groups for on-going support.

Representing the Lord Chancellor’s department, the Solicitor General, Harriet Harman, spoke at a meeting of the Intra-Party Parliamentary Group and told how one pregnant woman repeatedly went to her doctor with injuries. She was not asked anything about violence, and her relationship with her partner was never discussed. Subsequently he murdered her and their two children.

The health service has been the slowest of all agencies to tackle the subject of violence in pregnancy. Research shows that around 30 percent of abuse starts when a woman is pregnant, and that in an existing abusive relationship violence escalates with pregnancy.⁶ Yet at present only 27 percent of health authorities have written policies about domestic violence, and less than half have a designated officer for tackling it.⁷ The Royal College of Midwives and the Royal College of Obstetricians both now address the subject of male violence against women. But the Royal College of Psychiatrists has ignored the subject completely, though a large proportion of deaths of women in the year after childbirth are from suicide.

Help is most effective when developed in the context of a policy framework that includes all health services and statutory and voluntary agencies. Cooperation is vital.⁸

A model for how a project can be run is provided in the city of Leeds. There is a multi-agency approach involving the West Yorkshire Police and training medical students, senior house officers, obstetricians, gynecologists, the neonatal team, trainee GPs, midwives, health visitors, nursing students, healthcare assistants, hospital administrators and A and E staff. They have input into child protection courses and focus especially on the needs of black women, disabled women, and women who are marginalised for any reason. The workers in this project emphasise the huge need for pre-registration teaching of all health professionals. While this is happening in Leeds, it is not yet national policy.

Nurses and midwives are often concerned that to ask questions about abuse will alienate and anger women. Yes, some are shocked by questions they did not expect and that they consider intrusive. Yet a study in Sweden of pregnant women’s responses to being asked by their midwives whether they had experienced any violence revealed that 80 percent found the question acceptable, 17 percent were in two minds on the subject, and only 3 percent said it was unacceptable.⁹

The Royal College of Midwives suggests that questions which invite a woman to talk about violence can be general, such as "Is everything all right at home?" or more specific, such as: "Some women tell me that their partners hit them. Has that happened to you? I notice you have some bruising. Did anyone at home do that to you? Are you frightened of anyone at home? Is anyone hurting you at home? Does your partner break things that belong to you?" For this to be effective, women obviously need to be able to talk to their midwives without a partner or other family member present. Yet under half of all maternity hospitals offer any appointments without their partners.¹⁰

In the course of one training scheme for midwives it was discovered that though there was already a question about violence on the prenatal care booking form, midwives sometimes omitted the question, asked it, but did so in the presence of partners, or had no idea what to do if the woman said she was being abused.¹¹

Abused women have a right to confidentiality and their autonomy must be respected. They are most at risk if they decide to leave the relationship, and must not be put under pressure to do this.¹² A woman may be referred to a refuge and needs to work out an "exit plan" if she decides to leave home in a hurry, perhaps having a suitcase with clothes and other necessities, spare car keys and essential documents for her and her children, in a safe hiding place or with a neighbor. If she already has children, she should be told that if there is any chance that they could be harmed, confidentiality cannot be guaranteed. Women should be made aware of the help available through posters in toilets, booklets, and printed cards that give phone numbers of local and national Women’s Aid, police community safety units, victim support and social services - and these cards must be small enough to hide.

The needs of ethnic minority women have to be addressed with cultural awareness and sensitivity. Pregnant women from the Indian sub-continent are often accompanied to the clinic by a family member, usually a male – the partner or a young boy – to translate. Then it may be impossible to reveal abuse. Interpreters who are not family members should always be available. It may be important for caregivers to share their concerns with advocates from the minority groups involved, and perhaps help the woman get police protection, too.

A woman was forced into an arranged marriage at the age of fifteen with a man who wanted to emigrate to the UK. He could not get a visa and she returned home without him. Some years later she fell in love, got pregnant, and refused an abortion, though she was under heavy pressure from her family to have one, because of the disgrace of an illegitimate child for the family. Her midwives did all they could to help her, but then she told them that she had had a long talk with her mother and was out of danger. Everyone relaxed. At that point, a hired assassin killed her.¹³ Another woman, who left her husband because of his violence, which she disclosed during a prenatal visit, was offered support, but was murdered a few days after the baby's birth.¹⁴ Though all the relevant services were involved while she was pregnant, there was a complete breakdown in communication following the birth.

Ignorance, the trivialisation of abuse, and the failure of different agencies to collaborate, allows such violence to continue in a conspiracy of silence.

References