Royal Society of Medicine Forum: Domestic violence in pregnancy - Opening Pandora's Box. This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Thursday 13th November 2003. The meeting was chaired by Roxanne Chamberlain of the National Childbirth Trust.

The report has been published in The Midwives Journal of the Royal College of Midwives. It is reproduced here with their consent and our thanks.

Domestic violence and health
From Dr Loraine Bacchus (LB), Research Associate, Kings College School of Nursing and Midwifery and St. Thomas's Hospital London.

This study was the result of a research collaboration between St. George's Hospital Medical School Department of Psychiatry and the Maternity Service of St. Thomas' NHS Hospital Trust.

Although domestic violence occurs frequently and can adversely affect pregnancy, health professionals rarely enquire about abuse. The study examines the prevalence of domestic violence and its associations with obstetric complications and psychological health in women receiving care on antenatal and postnatal wards. In a cross-sectional survey conducted in the maternity service of an inner London teaching hospital 200 English-speaking women aged 16 and over were interviewed between July 2001 and April 2002. A modified version of the Abuse Assessment Screen (McFarlane et al. 1996) was used to assess for experiences of domestic violence. Depression was assessed using the Edinburgh Postnatal Depression Scale (Murray & Cox, 1990). The analysis of predictors of obstetric complications grouped together those known to be associated with domestic violence. Other data collected included: socio-demographic variables (age, ethnicity, civil status, employment status); health risk behaviours (smoking, illicit drug use, alcohol use); history of depression, suicide attempts, self-harming and suicidal ideation; and women's self-reported obstetric complications in the current pregnancy. Lifetime experience of traumatic events was assessed using the Post Traumatic Diagnostic Scale (Foa et al., 1997), and at 1 in 4 in this study is similar to that found in other UK studies. Women who disclosed domestic violence were also asked about their experiences of seeking help from health professionals.

Women who were very ill, had delivered a stillbirth or had a baby in Special Care were not approached to be in the study. However, some women with babies on Special Care heard about the study and requested to be included. In view of the sensitive nature of the project consent was obtained sequentially, first by asking women on the wards whether they would be prepared to participate in a maternity health survey; those who agreed were taken to a private room and given a fuller explanation of the study and asked for their consent again. None withdrew from the study once they knew the nature of the questions. All those who took part were offered details of local and national organisations providing support for women affected by domestic violence. Some of the women who did not report any abuse either asked for or accepted this information.

47 (23.5%) women had lifetime experience of domestic violence and 6 (3%) had experienced this violence during the current pregnancy. In the majority of cases (40, 85%) the perpetrator of the violence was a current or former partner or husband. Two of the six women who reported domestic violence during the current pregnancy had also experienced sexual violence during the pregnancy. Two said that the violence had started during the pregnancy; one woman said that it became worse during the pregnancy, and the remaining three reported no change. It is likely that the problem is underestimated, since women are often reluctant to disclose abuse, probably because of concerns about social service involvement. However, 3% of the 6,000 women attending the maternity service at Guy's & St. Thomas' Hospital each year would equate to 180 women a year, a significant problem. Although not statistically significant, a greater proportion of those with a history of domestic violence reported suicidal thoughts or attempted suicide.

Women with a history of domestic violence were significantly more likely to be single, separated or in non-cohabiting relationships, to have smoked during the current pregnancy or in the year prior to pregnancy, and were more likely to have consulted their GP with "nerves, anxiety, sleeping problems or feeling sad". Higher scores on the EPDS were significantly associated with domestic violence, being single, separated or in a non-cohabiting relationship, and with obstetric complications. Histories both of domestic violence and of increased depressive symptomatology were significantly associated with obstetric complications after controlling for other known risk factors such as maternal age, ethnicity, smoking, alcohol use, civil status, socioeconomic status and employment status. Half of the women who disclosed a history of domestic violence said that they had never discussed it with a health professional, citing fear, embarrassment, or anxiety that they might be blamed or disbelieved; some were hindered from communicating by low self-esteem or by a belief that they could not be helped. Others had waited in vain for a health professional to ask first.

The response rate on the postnatal ward, where women are tired, often in pain, preoccupied with their babies or visitors, and wanting to go home, was only 10 per cent, but was 58 per cent on the antenatal ward, where women might stay for extended periods. However, there was no significant difference in the reporting of domestic violence between the two groups.

It is difficult to explain the relationship between domestic violence and obstetric complications, when the majority of women did not experience the abuse during pregnancy. However, some studies suggest that its effects are cumulative and that women continue to experience poor health outcomes long after the abuse has ended. Ending an abusive relationship does not necessarily mean an end to the abuse or its adverse effects. It can lead to a number of difficulties as the woman tries to protect herself and her children, among them financial problems, poor accommodation, social isolation and continued harassment and abuse by the partner. Domestic violence, lack of social support and depression are known to be associated with poor obstetric outcome, perhaps because they lead to impaired self-care and consequent lack of attention to health problems, smoking, alcohol use, poor diet, late booking in the antenatal clinic, and poor attendance at appointments.

Training and study days are important as they raise awareness amongst professionals and instruct them in the steps to be taken when they meet clients suffering domestic violence. Information about the relevant support services must be widely available in maternity services, in different formats and languages. Health professionals and related services have an important role in raising awareness about the prevalent nature of domestic violence and its harmful effects. They can help to reduce the stigma and create environments that facilitate safe and confidential discussion about the issue.

References:
Murray D, Cox J. (1990) Screening for depression during pregnancy with the Edinburgh Postnatal Depression Scale (EPDS). Journal of Reproductive and Infant Psychology 8:63-65.
McFarlane, J., Parker, B. & Soeken, K. (1996) Physical abuse, smoking and substance use during pregnancy: prevalence, interrelationships and effects of birth weight. Journal of Obstetrical Gynecological and Neonatal Nursing; 25:313-20.

Foa E, Cashman L, Jaycox L, Perry K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychological Assessment 9: 445-451.

The silence of domestic violence in pregnancy during women's encounters with maternity and healthcare professionals
Dr. Gill Aston, (GA), Midwife, Lecturer in The Florence Nightingale School of Nursing and Midwifery, King's College, University of London

The research discussed in this presentation focuses on one aspect of a larger doctoral study titled “From the margins into the centre: Women's experiences of domestic violence during pregnancy”. Findings indicated that practices in maternity care settings were not orientated to meeting the needs of women. Those who had experienced domestic violence during pregnancy identified that trust in the midwife was a vital component of the woman-midwife relationship in order to facilitate discussion and disclosure. Other findings related to women's experiences and interactions with health visitors and doctors, showing the contingencies and characteristics that enhance positive and effective communication between women and healthcare professionals.

My particular interest in domestic violence was aroused when I observed how closely intertwined it was with the sexual politics of HIV and HIV antibody testing during pregnancy. The aim of the study was to examine women's understandings and experiences of domestic violence during pregnancy and to represent their views. In this context the perspectives and voices of women has been silent, muted or invisible for too long. The qualitative study explores women's experiences of domestic violence in pregnancy and their interpretations of it. My results and analysis extended into the six weeks after delivery, since nearly one third of the women reported that the violence became worse after the births of their babies. In depth interviews were conducted with 22 women, who were recruited with the help of a health visitor and a social worker and by means of an advertisement in the media. Two pre-prepared indices of violent acts and injuries, the Violence Assessment Index and the Injury Assessment Index were utilised on completion of interviews as a means of enabling women to describe the worst act of violence that they had experienced during pregnancy (Dobash & Dobash et al. 1996). The study was guided by the principles of research from a feminist perspective. Data analysis was based on the inductive process of grounded theory.

I found that when talking to their pregnant clients midwives did not raise the subject of domestic violence, which the women were unable to discuss despite wishing to do so. Their experiences were not being taken seriously; they were in effect invalidated, unexplored, unacknowledged, and silenced in the maternity care setting. (Gerbert et al. 1996). Women perceived the professionals as lacking interest or unsympathetic towards their needs, so that they felt isolated and alone in their experiences. Consistent with this finding, others have observed that midwives frequently do not address domestic violence during their encounters with women. I would argue that this is not because of their indifference, but because of a lack in their education and training, doubtless due to shortages of time, resources, and support. However we must not underestimate personal biases and negative assumptions and stereotypes about women who experience such violence, and these need to be targeted in training sessions.

Midwives' interactions with women in the maternity care setting are organised asymmetrically; they have been observed to have primary control of topic selection and closure, with women rarely attempting to control the agenda (Lomax & Robinson 1996). This is a clear abuse of social power (Dingwall 1980). Referred to as “silent womenmothers have been seen to speak little during antenatal consultations with midwives and even less when with doctors, and this has come to be regarded as normal and taken to indicate compliance and a lack of need for information (Kirkham & Stapleton 2001, p.144). Such findings are difficult to reconcile with the notion of an empowering and partnership model of midwifery care, and it makes it unlikely that women will either ask about or disclose domestic violence during pregnancy. In my study maternity care professionals were seen to focus on biological processes and the physical tasks of monitoring pregnancies and the wellbeing of the fetus, sidelining the experience of women with domestic violence in pregnancy. There is evidence which suggests that mechanistic and medicalised understandings of pregnancy and childbirth dominate the discussions between women and professionals (O'Connor 2002; Olsson et al. 2000). I believe that at a very fundamental level these approaches actively gloss over the psychosocial context and dynamics of violence directed against women during and after pregnancy.

In this study the concerns of women can be framed in the context of three issues: trust, inter-agency collaboration, and the availability of written information about domestic violence. Women need to feel that they will be believed, and that they will receive a non-judgemental response from midwives who are themselves confident and competent in the context of domestic violence. Perhaps midwives believe that women will automatically trust them, yet it is clear that in recent years there has been declining trust in professionals and public services (Giddens 1990). Trusting involves uncertainty, anxiety, and high levels of vulnerability and dependency; to trust another is to gamble on the ability of that person to act with integrity (Giddens 1990). A competent and knowledgeable health provider is willing to discuss abuse, to listen respectfully and respond in a way which expresses the effort to hear and understand a woman's concerns; is accessible, respects confidentiality, and shares decision making with women, demonstrating personal concern beyond the medical role through non-judgemental and compassionate gestures and persistent committed behaviour (battaglia et al. 2003). These researchers also suggest that trust is enhanced by empowering statements such as You did not deserve to be abused”.

Worried that their children would be taken away from them, women were in fear of statutory agencies being contacted, in particular social services departments, about child protection concerns. A particularly strong issue for them was that they felt that social workers were primarily concerned with child abuse and child protection. They also had realistic anxieties about the precipitation of beatings by their abuser when social workers visit. By virtue of their ability to engage with women, midwives are recommended to anticipate these fears as a likely source of concern for them. Midwives will need support and guidance from professional and voluntary organisations to deal with the sensitive issue of overlap between domestic violence and child abuse. Women who have experienced domestic violence can themselves provide valuable advice on what it is that leaves them and their children feeling safe or unsafe.

Opportunities to provide written material about domestic violence were not maximised in health care settings; general practice surgeries often failed to display posters or leaflets on the subject, leaving women uncertain whether this is a valid subject to take to their doctors, or whether the doctors will be interested or able to help them. Women saw such literature as evidence that they are not alone with their problem.

I found that health visitors were more likely than other professionals to integrate domestic violence into their work, giving their time and providing opportunities for their clients to open up about their experience of it; they also provided information about appropriate agencies, particularly refuges and sources of legal advice (Bacchus et al. 2003). Women reported general practitioners to be variable in their responsiveness to complaints of domestic violence and to obvious signs of injury. Doctors may or may not pick up clues offered by women reluctant to make direct statements, but they were generally prepared to give their GPs credit for some understanding and helpfulness.

Implications arising from the study point to the need for maternity and healthcare professionals to listen to women and to be aware of the difficulties women experience in asserting their need for dialogue and information about domestic violence during pregnancy.

References

Bacchus L, Mezey G, Bewley S (2003) Experiences of seeking help from health professionals in a sample of women who experienced domestic violence. Health and Social Care in the Community 11(1):10-18

Battaglia T A, Finley E, Liebschutz J M (2003) Survivors of Intimate Partner Violence Speak Out: Trust in the patient-provider relationship. Journal of General Internal Medicine 18(8):617-623

Dingwall R (1980) Orchestrated Encounters: An Essay in The Comparative Analysis of Speech Exchange Systems. Sociology of Health and Illness 5(2):127-149

Dobash R E, Dobash R P, Cavanagh K, Lewis R (1996) Research Evaluation of programmes for violent men. Edinburgh, The Scottish Office Central Research Unit.

Gerbert B, Johnson K, Caspers N, Bleecker T, Woods A, Rosenbaum A (1996) Experiences of battered women in health care settings: A qualitative study. Women & Health 24(3): 1-17

Giddens A (1990) The Consequences of Modernity. Cambridge, Polity Press.

Kirkham M, Stapleton H (2001) The culture of maternity care. In: Informed Choice in Maternity Care? An evaluation of evidence based leaflets – Report 20 Kirkham M, Stapleton H (Eds) Ch.16 137-149 The University of York, NHS Centre for Reviews and Dissemination.

Lomax H, Robinson K (1996) Asymmetries in Interaction: An Analysis of Midwife-Client Talk During the Postnatal Period. In: Conference Proceedings of 24th Triennial Congress of The International Confederation of Midwives 26-31 May, Oslo, Norway 252-255, The Hague, International Confederation of Midwives.

O'Connor M (2002) Consequences and Outcomes of Disclosure for Abused Women. International Journal of Gynecology and Obstetrics 78(3): Supplement No. 1 S83-S89

Olsson P, Jansson L, Norberg A (2000) A Qualitative Study of Childbirth as Spoken About in Midwives' Ante- and Postnatal Consultations. Midwifery 16(2): 123-134

Acknowledgements.

I thank all the women who took part in the study. Their strength was my source of inspiration.
Research Supervisor: Professor Rebecca Emerson Dobash.
Economic & Social Research Council (ESRC) Research Student Scholarship – Number R42200024023
Email

Routine questioning about domestic violence in maternity settings.
From Sally Price (SP), Midwife Consultant, North Bristol NHS Trust and the University of the West of England. Member, National Domestic Violence and Health Research Forum.

Domestic violence in pregnancy is not uncommon, and has serious implications for both maternal and child health. One woman dies every three days as a result of domestic violence. About 60 per cent of children who witness domestic violence are also abused by the same perpetrator, with a significant number of deaths ensuing. The Confidential Enquiry into Maternal Deaths 1997 -1999 states that prior to their deaths 12% of women had reported experiencing domestic violence (National Institute for Clinical Excellence et al. 2001). In many cases it appears that little or no help concerning the violence was offered to the women.

“She says the children are not affected by the violence - she tries to make sure they are not involved. Anyway he would never hurt the children.”

It is essential that public agencies take every opportunity to identify those who may be subject to violence, and by offering practical and emotional support, help prevent the situation from deteriorating. All health care professionals have the opportunity and responsibility to identify those who are experiencing domestic violence. It is vital that routine questioning is accompanied by appropriate protocols, training and support for staff (DOH 2000).

These admonitions are echoed inter alia by the Royal Colleges of midwives, obstetricians, and general practioners and by the National Institute for Clinical Excellence (NICE Guideline 2003), which have additionally recommended that the introduction of routine enquiry is accompanied by an educational programme for professionals and that appropriate screening tools are developed. Gentle and non-threatening direct questioning should be employed, since hedging around the issue will confer a sense of shame. Women should have the opportunity to discuss their pregnancy with a midwife in privacy, without their partner present, at least once in the antenatal period.

“I wish I'd been asked about what happened. I was so ashamed, but I really wanted to tell them. They didn't ask me and I didn't have the courage to tell them.”

Most women, including victims and non-victims, do not mind being asked about their experiences of violence, and they often do not understand the failure of health professionals to ask in depth about the cause of their injuries or health problems. Routine enquiry for domestic violence is acceptable to women in maternity settings if conducted in a safe confidential environment by a trained health professional who is empathetic and non-judgmental, but in the general practice setting at least 20% of women said that they would object to being asked about abuse or violence in their relationship if they had come about something else. (Davidson et al. 2000; Bacchus, Mezey and Bewley 2002; Richardson et al. 2002).

A systematic review (Ramsay et al. 2002) found that insufficient evidence exists to show whether screening and intervention can lead to improved outcomes for women identified as abused, and concluded that implementation of screening programmes in health care settings is not justified by the current evidence. However this review is of doubtful validity, since none of the research reviewed was conducted in the UK, none took place in maternity settings, all had substantial methodological weaknesses, and they did not include qualitative research on domestic violence. Furthermore it has been pointed out that research on screening is inappropriate because outcomes cannot be measured. Positive intermediate outcomes such as referral should be enough to justify screening, and rejection of screening should not be viewed as avoidance of any action by health professionals. (Feder 2002)

An audit carried out by the North Bristol NHS Trust in 2002 (Price S and Baird K 2003) had 88% feeling that it is the health professionals role to ask about domestic violence in pregnancy, but only 61% believed it should occur routinely. Asked who should ask, it was to be any group other than their own! Community based midwives clearly saw asking as an integral part of their role, perhaps because they are better able to develop trusting relationships.

The National Screening Committee criterion for screening is that both test and treatment should be viable, effective, acceptable and agreed. They conclude that there is no evidence that screening is clinically, socially and ethically acceptable to health professionals and the public. Screening may be inappropriate; routine questioning is not, but if we ask the question we must be able to deal with the answer. A national policy is needed, giving women the opportunity to disclose. It must include quality assurance measures to guarantee standardisation, but it will be of no value without adequate resources and support services, and a genuine commitment on the part of the maternity services.

Conversely, if the question is not asked women will continue to experience violence with little hope that the health service will offer appropriate and timely support and advice. Health professionals will fail in their professional responsibility, and they could carry a burden of guilt for the omission.

Do health professionals want to ask? Probably not. They are discouraged by conflicting evidence around screening, lack of managerial support and resources, and the fear of opening a can of worms. "How can I find the time in a busy clinic?" They are embarrassed, and fear intruding into the private domain of the family. A serious sensitivity for some is their personal experience of domestic violence. They need to develop knowledge and skills, and must address negative attitudes and stereotypical beliefs, and must have access to support when dealing with sensitive issues.

Changes in practice are essential. Appropriate education and training, support and supervision have to be ongoing. The necessary resources, particularly time for discussion with women, have to made available. Collaborative partnerships, not only with health professional groups, but also with voluntary organizations, the police and social services should be set up. Work is needed to establish how these changes are to be implemented. It is hoped that a national policy will be incorporated in the National Service Framework for Children.

It is at present unknown what costs will ensue upon these changes. The impact of routine enquiry on health professionals who have personal experience of partner abuse deserves study, and so most importantly does the impact on women's lives.

University of the West of England research project.

    An impact evaluation of an education and support programme to promote routine antenatal enquiry for domestic violence within North Bristol NHS Trust. Funded by the Department of Health.

    · Enquiries

    References:

    National Institute for Clinical Excellence, The Scottish Executive Health Department, and The Department of Health Social Services and Public Safety: Northern Ireland. (2001). The Confidential Enquiries into Maternal Deaths in the United Kingdom. Why Mothers Die 1997 – 1999. London. RCOG Press.

    Department of Health (2000) Domestic Violence. A resource manual for Health Care Professionals. London. HMSO.

    National Institute for Clinical Excellence (2003) CG6 Antenatal Care – routine care of the healthy pregnant woman. NICE Guideline. www.nice.org.uk

    Davidson, L. King, V. Garcia, J. Marchant, S. (2000) Reducing Domestic Violence - What Works? Health services. Policing and Reducing Crime. Briefing Note. London. Home Office.

    Bacchus, L. Mezey, G. Bewley, S. (2002) Women's perceptions and experiences of routine enquiry for domestic violence in a maternity service. International Journal of Obstetrics and Gynaecology. Jan 2002 109: 9-16.

    Richardson, J. Coid, J. Petruckevitch, A. Shan Chung, W. Moorey, S. Feder, G. (2002) Identifying domestic violence: a cross sectional study in primary care.
    BMJ, Feb 2002; 324: 274.

    Ramsay, J. Richardson, J. Carter, Y. Davidson, L. Feder, G. (2002) Should health care professionals screen women for domestic violence? Systematic review. BMJ. 325: 314

    Feder, G. (2002) Systematic review of screening for domestic violence: not an excuse for clinicians to ignore abuse. Presentation to the National Domestic Violence and Health Research Forum. London October 2002.
    Also see http://bmj.com/cgi/eletters/325/7359/314#27187 20 Nov 2002.

    Price, S. Baird, K. (2003) Domestic Violence: An audit of professional practice. The Practising Midwife. Vol 6 no 3: 15-18


    Discussion.


    SP: My routine enquiries have so far never elicited an admission of violence at the first interview; it has always come up at a subsequent meeting. We have increased our identification of domestic violence in pregnancy about 10-fold in an admittedly short period of time; this may be due to routine questioning or to the environment we have created which facilitates disclosure. While it may seem that the subject has rapidly become a hot topic, here in Bristol we have been addressing it since 1997.

    SP: Continuity of carer and the development of trusting relationships are two sides of the same coin.

    SP: Practical matters in the clinic. The first priority is safety; has the woman a safe place to return to? Has she decided to leave her partner, or does she only want to tell somebody? I need to manage clinic time, and may ask the mother to wait a while until I can find a half-hour slot. We have to give women information to enable them to make choices. We don't tell them what to do, but where they can get more support, more advice, more information, informed choice in fact. Social services, the police, the voluntary sector, her GP - the choice must be hers, although the voluntary services are my preference. I help her by providing sufficient detail about each of these choices.

    Policewoman Yvonne Roden: Prescriptive advice is to be avoided where such vulnerable women are concerned. I agree that the fear with social services is that children may be removed from the family. As well as the advice Sally has given you, I would add making the perpetrator accountable for his actions. Safety comes first; we might recommend Women's Aid or a refuge, but would never suggest using the criminal justice system, which is another object of fear for these women. We, like you, give them the options and support them in their choices; we do the same for you as professionals.
    Domestic violence accounts for one quarter of all murders in London at present; if gun-related crime is excluded the level reaches 40 per cent. Children are prominent among the victims.

    Wendy Savage: Some terrified women turn to termination of pregnancy as the only possible solution for them. In one area the police might be the best agency to which to turn, in another it might be social services. "Listen to the patient; he is telling you the diagnosis" (Osler). You will not get the right answer unless you ask the right question. Sometimes the professional needs courage.

    LB: Correcting for the various factors which I mentioned still left domestic violence as a significant factor in poor obstetric outcome.

    SP: Midwives who are in doubt about the value of inquiring for domestic violence are usually convinced when the the issue is seen to be allied to child protection.

    Steve Bradman of the Metropolitan Police Community Safety Unit: How many women had suffered prior domestic violence? GA: The majority, almost always before pregnancy. My advertising to recruit women for my study was often their first opportunity to discuss domestic violence. Other researchers have seen the need for such creative methods.

    A midwifery lecturer recommended discussing with students attitudes around this issue, and told of one, who had been through drama school, who suggested making a video simulation of clinic interviews.

    GA: In the past health visitors have been among the most proactive professionals in helping the victims of domestic violence; now their practice seems to be too much research
    -based.

    LB: Most research has shown a prevalence of disclosure of domestic violence in pregnancy of about three per cent, as did ours, in which the rate increased to five per cent in mid-pregnancy. I could have wished that our questionnaire had addressed psychological as well as physical violence, and I believe that the actual prevalence is much higher than three per cent, and that this would be revealed if questions are asked about a larger range of abusive behaviours. (This was confirmed by a Dublin social work researcher, who stressed that disclosure is a process, not an event. Sometimes it is appropriate to reassure a woman that her coping is adequate for now, but that there are other resources open to her if they become necessary).
    Women so often persist in abusive relationships that this induces a feeling of impotence in the professionals who would wish to be helpful, and discourages them.

    Mary Newburn of the National Childbirth Trust: The abusive partner is a life partner, and transferring allegiance to another may make a woman feel even more vulnerable, and is liable to cause great emotional and social upheaval. Listening remains good therapy. The role of the health professional is to give women information so that they may make their own choices; it is not a search and rescue operation.

    SP: Screening has not been validated, and probably never will be. This does not subtract from the value of routinely questioning, for which midwives already have the skills, without the necessity for a tool.

    SP: Midwife training in this area involves influencing attitudes. Role play, although not popular when introduced, is seen to be very effective. We make opportunities for the discussion of actual cases, and encourage exchange of information. Supervisors of midwives can and do act as a forum for the support of midwives working with domestic violence.

    LB: The National Domestic Violence Health Practice Forum now exists to standardize training and protocols, and I would encourage all to join the Forum and benefit from it. This should prevent profitless overlap and repetition.

    SP: There is a valuable Home Office leaflet (2002), free of charge and published in a number of languages, entitled Loves Me Loves Me Not. Women's Aid is an excellent resource to which women and professionals should turn. A social worker attached to Women's Aid mentioned that they are currently exercised about confidentiality and legal aspects.

    Information in clinics. Posters; inside the doors of women's toilets; "Put a sticker on your urine pot if you want to talk about domestic violence in confidence with your midwife"; free leaflets can be collected from police stations, safety units, and domestic violence units, along with comprehensive contact information. One unit provides information on pieces of paper small enough to conceal in a shoe; another hands it out in visiting card format.

    LB: Disclosure of sexual abuse is at a very low level probably because of the shame which women feel on this subject; otherwise the way the question is phrased may miss it, and women may not see it as violence.

    A plea from the chair: If you are, or your organization is a resource for information on domestic violence, please telephone local maternity units to enable them to contact you easily when needed. And please see the NCT publication The Woman Who Walked Into Doors.

    References:

    For AVA (Against Violence & Abuse):
    Downstream Building
    1 London Bridge
    LONDON SE1 9BG
    United Kingdom
    tel: 020 7785 3863 fax: 020 7785 3865
    Email:

    Refuge
    4th Floor, International House,
    1 St Katharine?s Way,
    London E1W 1UN
    Freephone 24 hour National Domestic Violence Helpline run in partnership between Women?s Aid and Refuge: 0808 2000 247
    To contact the Research Co-ordinator of Refuge, Parvinder Dahri-Cooper