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Introduction
One in four women are victims of domestic violence, at some point in their life with violence escalating during pregnancy. This clearly makes the subject a health care issue for all health care professionals including midwives and the women in their care (DOH 2000). However, the subject can be undervalued, particularly with reference to antenatal screening, and the support of women thereafter as some midwives believe that this subject is not their business (Bewley & Gibb 2001).
Midwives may question whether it is considered to be part of their role to intervene, or whether their role is simply to continue to support women through the medical and physical processes of childbirth. This negative attitude may be directly resultant of a dichotomy between theory and practice. This may occur as a result of lack of education within this area and supports the value of evidence based practice.
The purpose of this in depth study is to examine the position of midwives in screening for domestic violence and supporting sufferers of domestic violence. Where midwives are now and what they need to know and do in order to move forward will also be considered.
Firstly the author considers it appropriate to include a historical background relating to the subject of domestic violence. A problem statement will also be included. Current research relating to the subject of domestic violence will be included in a literature review, and will be critically appraised, in an
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attempt to update both the existing knowledge of the author and of the
reader. A critical analysis of the topic of domestic violence in pregnancy
will be included in the form of chapters, followed by a conclusion including recommendations for change in practice.
Current practice within the author's workplace will be evaluated and examined, in an attempt to improve quality of care and practice for the future. The study will also incorporate the English National Board (ENB) ten key characteristics.
The author of this in depth study is an F Grade midwife working within the maternity unit of a National Health Service hospital. This role incorporates rotation into the local community. The topic was chosen by the author due to an interest in the problem of domestic violence, and a belief that there is a case for positive midwifery intervention within the subject. The author will attempt to demonstrate this throughout the study.
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Historical Background Relating to Domestic Violence
In order to give the reader a full understanding of the subject, the author feels it is essential to include some historical background relating to the subject of domestic violence.
Although domestic violence is not gender specific for the purpose of this study the author is referring to female victims of violence especially those who are accessing maternity services. The term domestic violence will be used throughout and is referring to the emotional, physical, psychological, and sexual abuse of women by their intimate male partners and ex-partners whether married or living as a couple (Williamson 2000).
Historically domestic violence was accepted, with resistance being a much more recent occurrence. Until the nineteenth century husbands had a legal right to beat their wives for what was considered to be "lawful correction". This was not illegal as long as the husband abided by the "Rule of Thumb". This was a general rule operated by the courts permitting husbands to hit their wives with a stick as long as that stick was not broader than their own thumb. However this rule did not apply at weekends or after 10pm as it may disturb the neighbors whilst they were praying (1765/cited by Bourlet 1990).
De Beauvoir (1974) highlighted the link between Christianity and the law: Men enjoy the great advantage of having a god endorse the code, he writes :
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"and since man exercises a sovereign authority over women it is especially fortunate that this authority has been vested in him the Supreme Being".
Therefore suggesting that God gives powerful authority to men to exercise as they wish.
There is evidence of domestic violence in Roman times. Mr. Punch is derived from a Roman mime called Maccus (Brewer 1978). As far back as Ancient Egypt women who spoke out against their husbands where said to be liable to having their teeth hit with a brick (Bourlet 1990).
In 1971 Dobash & Dobash (1980:2) stated that almost no one had heard of battered women, except the legions of women who were victims and the social workers, ministers, families, doctors, lawyers and friends in whom some of them confided.
In the early nineteen seventies activists discovered that victims of domestic violence were poorly treated by the criminal justice system. The police in particular did not take positive action against perpetrators of domestic violence (Fearns 1988).
Domestic violence often begins or escalates during pregnancy (CEMD 1999) and is not exclusive to any particular culture or social class (Steen 2000). Almost nine out of ten children who experience neglect reported domestic violence occurring in the family home (NSPCC 2002). Highlighting an overlap between child abuse and domestic violence.
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Erin Pizzey opened the first officially recognized women's refuge in 1969. Demand for safe accommodation for abused women and their children was
so high that the refuge was massively over populated. Ms Pizzy declared that she would not turn any woman and child away who was in need of safe accommodation. The Women's Aid Refuge service operates on this principle today (Hunt & Martin 2001).
On average, a woman will be assaulted by her partner or ex-partner 35 times before reporting it to the police (Bewley Friend & Mezey 1997). Women's Aid publish a national survey, the 1996-97 found that over 35,000 women called Women's Aid National Domestic Violence Helpline in the year of 2000 (Women's Aid Federation 1997). The police receive 1,300 calls each day and 570,000 each year from women experiencing domestic violence with the estimated total cost of domestic violence for the Greater London area alone being around 278 million pounds per annum (Stanko et al 1998).
Without screening for domestic violence in pregnancy many victims will remain undetected (Price 2001) therefore highlighting a need for midwives to be educated in sensitive screening of pregnant women.
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Problem Statement
There is a need for midwives to have adequate preparation to screen for domestic violence during the antenatal period. Education and understanding is essential in order to provide support throughout the childbearing continuum. Incorrect preparation of midwives when dealing with women suffering from domestic violence may add further distress. This is endorsed by the Nursing and Midwifery Council Code of Professional Conduct (NMC 2002) Clause: 6.2 which states that to practice competently a midwife must possess the knowledge, skills and abilities for safe effective practice. Clause 6.3 states that a midwife should not practice beyond her level of competence but should seek help or supervision from a competent practitioner until the requisite knowledge and skills are acquired. This suggests that midwives have not just a moral, but a professional obligation to improve their skills and knowledge within this area.
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Literature Review
Domestic violence in general has created a wealth of literature and research. Much of this literature dating from the late nineteen eighties to present date. Whilst undertaking this literature review it became clear to the author that until recently less has been written in relation to women's experiences of routine enquiry about domestic violence during pregnancy. This study will provide an up to date review and analysis of recent literature surrounding the subject of screening for domestic violence during pregnancy.
Bacchus, Bewley & Mezey (2002) undertook a piece of research titled "Women's Perceptions and Experiences of Routine Enquiry for Domestic Violence". The title of the piece clearly informs the reader of the purpose of the work. The data presented in the study form part of a large scale Economic and Social Research Council project on the prevalence of domestic violence in pregnancy. The Economic and Social Research council therefore provided funding. An abstract is not included in this piece of work, ethical approval was received from St. Thomas' Hospital Research Ethical Committee before commencement of the research. The study was conducted in the maternity services of two large teaching hospitals in south London. Consent was obtained from all participants and thanks were given in the final published article, as was a ten-pound gift voucher to all the women involved.
The work takes the form of a qualitative study, which examines women's experiences of routine enquiry for domestic violence in a maternity service
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setting. The design used was purposive sampling to select a subsample from a larger group of women who participated in the research undertaken at Guy's and St. Thomas's Hospitals in London.
A cross sectional survey was used to assess the prevalence of domestic violence in pregnant women booking for maternity care between 14th September 1998 and 21st January 1999. The women were assessed for domestic violence at the booking appointment, at 34 weeks gestation and once within 10 days post delivery. They were interviewed in the home, hospital, or community antenatal clinics, privately by midwives. Only professional interpreters were used, as it would be considered to be unethical to ask friends or family members to interpret. Women were assured of confidentiality, provided with information and assured that their care would not be compromised should they not wish to participate.
Prevalence of domestic violence was assessed using a variation of the Abuse Assessment Screen (see appendix 1). This is where women are given a response card with a list of possible perpetrators of violence. The cards included responses for many specific questions including types of injuries, frequency of attacks. A body map picture was used to determine the site of injury. Women were asked at the end of the interview whether they found it acceptable to be asked about domestic violence.
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Midwifery training of interviewers was undertaken. The interviewers consisted of 145 midwives from 8 hospital teams and 10 community teams. Specialist midwives and midwifery managers were invited by letter to attend
a training session. A manual based training pack was used which was designed by the research team. On average each training session lasted two hours although this varied. Of these 116 midwives 80% attended a training session. Prevalence, effects of domestic violence using the screening instrument and general education and information was provided at the sessions. Training lasted from July 1998 to March 1999.
During the post partum period (less than one month to 14 months) purposive sampling was used to select women who had participated in the domestic violence screening study. These women were then involved in a semi-structured interview. This method of sampling allowed the researchers to use their own judgment to select the most appropriate people to be studied to answer the research questions. It is difficult to decide whether or not this would bias the research. The sample consisted of 10 women who reported domestic violence in the current pregnancy 6 women who reported violence in the last six months, but not in the current pregnancy and 16 women with no history of domestic violence. Lorraine Bacchus who is one of the researchers conducted interviews. The author believes that a great deal of self discipline is required when a researcher is also responsible for interviewing subjects involved in the study as the interviewer may be open to bias, as they want the research to provide certain findings. Women were telephoned or contacted by letter on the pretense of inviting them to participate in an interview on women's views of their care during pregnancy.
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Data Collected included demographic characteristics, smoking, alcohol, drug use, psychiatric history, and childhood experiences of witnessing and/or
experiencing violence perceived acceptability and relevance of enquiry of domestic violence.
Results showed that at booking screening data was available for 718 women out of 771 who participated in the study. Of these 99% of women said they found it acceptable to be asked about domestic violence by a midwife. At 34 weeks gestation 100% of women who were screened found it acceptable. At the postpartum screening 99% women said they found it acceptable to be asked about domestic violence. There was no difference in the views of the women in the semi-structured interviews that had experienced domestic violence, to those who had not.
The women involved identified various factors, which were both positive and negative aspects of the screening. Some women identified practical issues such as time constraints of the midwives due to under staffing. Other women were worried that to disclose such information would suggest that their existing children may be at risk and a social worker may then be called. Some women felt they were asked very routinely, possibly just as routinely as booking questions about pregnancy history were asked and that midwives quickly moved on to the next question, sometimes following a yes response.
In a more positive light some women felt reassured to be asked and just to talk to some one. Another response was that midwives showed a genuine
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Interest in the health and well being of the pregnant women. Other women commented that the midwives did not seem shocked or judgmental.
Empathy concern and genuine understanding from midwives were much more important issues than the sex of the interviewer.
The study suggests that women did not appear to mind being asked about domestic violence, indeed, some women were relieved to be asked. The suggestion that onsite specialists may be required, was also made which does seem an excellent idea but may require further research in the future.
The author feels that the study is readable and workable and successfully informs the reader of its purpose. It is logically written and explores every aspect of this very complex ...
This is a preview of the whole essay
Empathy concern and genuine understanding from midwives were much more important issues than the sex of the interviewer.
The study suggests that women did not appear to mind being asked about domestic violence, indeed, some women were relieved to be asked. The suggestion that onsite specialists may be required, was also made which does seem an excellent idea but may require further research in the future.
The author feels that the study is readable and workable and successfully informs the reader of its purpose. It is logically written and explores every aspect of this very complex topic.
Stenson,Saarinen et al (2001) have produced a similar piece of research in Sweden, which also highlights the same suggestions and findings. Therefore implying that the management of this topic is not just applicable in the United Kingdom. The study is called "Women's Attitudes to being asked About Exposure to Violence". The study was conducted in Upsala, an average sized university town in Sweden. The research was carried out within all of the antenatal clinics within the town.
The researchers included 2 midwives, a director of a rape crisis center, and a senior lecturer from the health department of the university. The research also aimed to examine women's attitudes to being questioned by their midwife during and after pregnancy, about exposure to violence. The
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participants were pregnant women registered for antenatal care before 34 weeks of pregnancy, during a period of six months.
The design was in the form of an explorative study using content analysis of one open-ended question. Although an abstract is not included the objective, design, setting, participants, measurements, findings, conclusions and implications for practice are all clearly stated at the beginning of the study. This gives the reader a clear overview of what the research is about. It is possible however that this may discourage the reader from looking at the whole piece of work. Surprisingly there is no mention of a literature review having been included.
The work is described as an explorative study using content analysis of open-ended questions. This means that the research is seeking to find specific factors (Polgar & Thomas 1995) and information is collected and analyzed to establish themes (Rees 1999).
The introduction clearly identifies the problem and objective of the study, no limitations to the study are stated. Women were randomly chosen with no reference as to how they were chosen which might bias the study. Ethical approval was sought prior to commencement of the study. The Crime Victim Compensation and Support Authority provided financial support.
The article and findings were written and then translated into English, it was then translated back to ensure that the content was captured. This would also ensure that the findings were relevant to the British pregnant population.
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The study involved investigating the prevalence of physical violence, both during and after pregnancy and women's reactions to being questioned routinely about violence.
Data analysis was in the form of content analysis, which means answers to open-ended questions, were scrutinized. Researchers followed rigid and explicitly formulated rules and guidelines for categorizing so that two people could be involved in analysis of material, but obtain the same results. This is intended to avoid manipulation of data and ensure reliability. For quantitative data analysis, the Statistical Package for the Social Science version 8.0 was used. Results were printed in clearly labeled tables making reading and understanding of the main findings of the study easier. A well-balanced discussion was included and the conclusion supported the findings from the research and made recommendations for change of practice.
The findings of the above study also suggested that women do not mind being asked about exposure to violence. However, the midwives taking part in this study were educated on the subject prior to the research and it appears they were receptive to the education provided. This in turn could be the reason for the positive outcome.
A piece of work titled Screening for Abuse: Barriers and Opportunities produced by D'Avolio, Hawkins, and Haggerty et al (2001) acknowledges domestic abuse as a leading cause of death in women of childbearing age in the United States. The objective of the study is to discover how pregnant
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women's psychological and behavioral responses to abuse affect childbirth outcomes.
A literature review was carried out, but whilst this review was extensive and interesting it focused more on women who had attended accident and emergency departments with injuries resulting from domestic violence.
The study involved the screening of every pregnant woman for abuse, using an Abuse Assessment Screen (AAS). Eight different antenatal areas were used these included a major public hospital, a small city hospital, a community health center and two hospital based clinics. Nurses, nurse-midwives and nurse practitioners carried out the screening and were each given training by a member of the research team. Training included techniques for screening and what to do if a woman revealed abuse and requested help.
The subjects were pregnant women from different backgrounds including Hispanic, Haitian, Southeast, Asian, Brazilian, African American, Asian American and European American.
The results varied widely, abuse ranged from all but 12 women over a two and a half-year period in one area to no screening for abuse in another area. To date, 41% of women cared for by the study sites have been screened for abuse, 59% have not. Among the women being screened using the Abuse Assessment Screen, 16.3% admitted to having been emotionally abused and 7.2% in the past year.
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The study indicates inconsistencies between provision of training and the success of training. Retraining was provided for health care professionals, but inconsistencies remained, possibly due to the health care system and health care providers. There appeared to be several reasons for this, which included lack of commitment from managers, changes forcing chaos in the health care system, turn over and lack of commitment from staff. There were inconstancies in when women actually booked and whether they simply bypassed the booking visit due to advanced gestation, therefore missing the screening. Some staff members used the Abuse Assessment Screen others did not, some simply did not refer to the subject at all. The research was over shadowed by poor documentation, lack of policies or protocols, turnover of staff or temporary staff and general lack of staff interest or willingness. Some staff also acknowledged their own feelings of personal family violence as a barrier to screening. It is not stated whether women saw the same health care provider at each visit which may also be a barrier to successful screening. Women may have responded well to the same health care provider if they had managed to build up a relationship with that person. The reverse could apply however, if the pregnant women saw the same health care provider and did not gel with this person.
The authors state that the main purpose of the research is to determine how pregnant women's psychological and behavioral responses affect birth outcomes. This is never really addressed in the study, as the main focus of the work is barriers to domestic abuse as the title of the work suggests.
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During this literature review the author has found a great deal of literature and research on the above subject produced in the United States of America. This has given the impression that the United States may be much more advanced on the subject of domestic violence and pregnancy, than the United Kingdom. This ideology is not validated by the study and the author did not find this piece of work reassuring. The work indicates that the United States is no further advanced on the subject of domestic violence screening in pregnancy. Clearly defined protocols are not indicated for health care providers, continuity of health care provider is lacking. Staff apathy was also a major obstacle to this research.
On a more positive note following staff retraining and protocol implementation, the detection of domestic abuse in pregnancy did increase. The study also indicated that if screening is included in routine care, then health care professionals are more likely to screen.
Scobie & McGuire (1999) carried out research in the form of a pilot study titled "The Silent Enemy: Domestic Violence in Pregnancy". Both researchers are midwives, one working within a maternity unit the other working as education and research officer for the Royal College of Midwives. The study was completed in part fulfillment of a master's degree in midwifery. Quantitative methods were used, with the study looking at the concept of domestic violence in pregnancy exploring midwives knowledge and experience of the subject. On initially looking at the study, the title does
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not clearly inform the reader of the purpose of the work. The title was suggestive of the study being a generalized piece of work on domestic
violence. It did not indicate that the study looked specifically at the role of the midwife within this area. An abstract is included which makes the work much clearer and explains that the work does indeed explore the midwives knowledge and experience of dealing with domestic violence. The work does not include either an introduction or a literature review. The respondents were clearly defined as a group of one hundred randomly selected midwives practicing at grades E, F, and G, from two midwifery units. A letter explaining the study and requesting consent to approach midwives was sent to the clinical coordinator and clinical service manager in both units. Methodology was clearly stated. Questionnaires were developed consisting of mainly closed questions. A series of Likert-Style statements was devised to establish midwives attitudes towards domestic violence. Midwives were asked to rate whether they agree through to strongly disagree with the statements. According to Polgar & Thomas (1994) this type of questioning can give rise to middle responses all the time. The number of positions between the beginning and end points enables or allows the "no opinion" option (Oyster, Hanten, Llorens 1987). This may allow for a largely "middle of the road" or generally undecided response, allowing the respondent to "sit on the fence". The work describes the main findings of a pilot study which is reassuring as piloting or using a trial to test a new questionnaire with a small group of respondents will remove problems and improve clarity prior to commencement of the main study. The work does not say whether the researchers intended to carry out a larger piece of research following the pilot study or whether ethical approval was sought.
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Inclusions and exclusions were not mentioned. Statistical analysis was carried out using Microsoft Excel software ensuring accuracy. Results were
listed in the text and not in the form of graphs or tables which may have been useful to the reader. Discussion takes place under two headings which are "Dealing with the problem" and "Who should take the lead role?" A conclusion is included which identifies the implications of the work and is supported by the results obtained. The conclusion acknowledges that the study is small therefore suggesting that there may be a need for a larger study. It also acknowledges that the findings suggest that there are gaps between education and practice and that midwives are reluctant to get involved in the problem due to a perceived inability to help women. Key points are summarized at the end of the work highlighting the main points of the study for the reader.
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Chapter One - Setting the Scene
In order to develop an understanding of the subject we must first ask the question, " What causes men's violence towards women? " and more specifically " What causes this violence during pregnancy?" The author intends to include a general chapter, which will include the nature, perceived causes, effects and outcomes of domestic violence. Consideration will be given to the subjects of biological theory, gender, class systems and poverty. It is the author's intention that this chapter will set the scene and ensure greater understanding and clarity for the reader throughout the remainder of the study.
Haraway & O'Neil (1997) describe a multivariate model explaining men's violence towards women. The multivariate approaches explain the perceived causes of men's violence in the form of four factors (see appendix 2). These factors are as follows-:
Macrosocietal Factors - which are defined as patriarchal and institutional structures that cause oppression against women. These factors can include a history of violence, changes in gender roles that may activate men's fear of power loss. This factor questions how the larger society contributes to men's violence against women.
Biological Factors - these are included and are defined as hormonal, neuro anatomical dimensions of men, which cause violence against women. These factors include physiological processes with the major question being "is men's violence towards women biologically based?"
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Gender Role Socialization Factors - are included and are defined as men's sexist attitudes emotions and behaviors learned throughout life which cause violence towards women. This factor emphasizes how men are socialized restrictively to patterns of gender role conflict, misogynistic attitudes and negative emotions towards women. The central question being " Does mens gender role socialization and conflict cause mens violence towards women?"
Relational Factors - Are defined as ongoing interpersonal and verbal interactions between partners and may cause men's violence towards women. This factor emphasizes the verbal and emotional communication patterns and experiences between partners that may cause men's violence towards women.
Biological endocrine theories are sometimes used in an attempt to explain violence towards women. Increased levels of the male hormone testosterone is suggested by some researchers as an explanation for violence, however whether there is a connection between correlation and cause remains to be seen. Although testosterone levels have been linked to aggressive behavior in other mammals (Svare & Kinsley 1987), the mechanisms that explain the links are unclear. Animal research suggests that fighting can lead to both increases and decreases in testosterone levels depending on whether the animal wins or looses respectively (Rose, Bernstein & Gordon 1975). In one study college wrestlers who won their matches showed greater levels of circulating testosterone than losers (Elias 1981). However, the same results were found in the case of winners and losers of tennis matches - a game that
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involves activity, competition, but not violence (Mazur & Lamb 1980). Hunt & Martin (2001) dispute the theory that raised testosterone levels are
linked to violence stating that this would not account for the higher levels of aggressive behavior in pre-pubescent boys at ages prior to testosterone reaching significant amounts.
Researchers as a potential cause for violence towards women have also considered genetic theories. Research into the genetic origins of violent behavior includes studies of the heritability of violent traits and the effect of genetic anomalies (Greene et al 1994). Walters (1992) performed a meta-analysis of 38 family, twin and adoption studies to examine the connection between genetics and criminal behavior. He reported that the studies published after 1975 were better designed than earlier studies and provided less support for a gene-crime relationship. He considered that there was only a weak gene-crime correlation. Mednick, Gabrielli & Hutchings (1984) found that adopted children of criminal biological parents were likely to engage in criminal behavior. However, this apparent genetic link was true only for criminal activity and not specifically for violent crimes.
Researchers have considered as Neurochemicals or transmitters such as Serotonin, Norepinephrine, Dopamine and Monoamine Oxidase (MAO) as potential causes of violence towards women. Suggesting that Serotonin plays an inhibitory role while Norepinephrine and Dopamine each play a facilitating role (Raine 1993). Lower levels of serotonin metabolite were associated with a lifetime history of aggressive behavior and suicide attempts in one study, Brown et al (1982) Linnoila et al (1983) found
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relatively low concentrations of serotonin in the cerebrospinal fluid of impulsive violent offenders. The lowest levels found were in those who had
attempted suicide, therefore highlighting a link between low concentrations and a tendency towards violent behavior directed at oneself as well as towards others. This may suggest benefit from pharmacotherapy for perpetrators of impulsive violent behavior towards women.
According to Haraway & O'Neil (1999) the brain has specific areas that correlate to behavioral and physiological functioning, therefore suggesting that areas within the brain which are functioning incorrectly could impact on an individuals behavior. Brain dysfunction is a theory suggestive of causing an individual to express violent behavior. Studies examining the effects of damage to frontal lobe function have shown a pattern of behavior changes including argumentativness, lack of concern for consequences of behavior, loss of social graces, impulsivity, distractibility, shallowness, lability, violence and a reduced ability to utilize symbols (Raine 1993). It is thought that frontal lobes especially the orbit omedial areas, are involved with the inhibition of inappropriate behaviors (Volavka 1995). Frontal lobe dysfunction has been found in criminal and violent subjects in a direct positive relationship with severity and frequency of violence. Despite this, violent crime has not significantly emerged for nonviolent individuals who incurred a lesion of the frontal lobe (Volavka 1995) therefore suggesting this may be a moderator of violence rather than a cause.
In reference to domestic violence in pregnancy, the actual act of violence may be triggered or escalate as a result of pregnancy (Bewley & Mezey
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997). For many couples the arrival of a baby is a happy time, for some women pregnancy is far from a time of safety and may result in an increase
in existing patterns of violence. Taylor-Brown (2001) acknowledges that there is some correlation between domestic violence and pregnancy, but questions whether pregnancy constitutes an actual cause. Gazmararian et al (1996) urges caution when studying the subject as he suggests that studies typically lack direct comparison between the pregnant and none pregnant woman.
Despite this view domestic violence in pregnancy is of such relevance that a separate chapter was included on the topic in the most recent Confidential Enquiry into Maternal Deaths in the United Kingdom (CEMD 1997 - 1999). In this triennium 45 (12%) of women whose deaths were investigated self reported a history of domestic violence. The figure is likely to be an underestimate of the prevalence of domestic violence, as it appears that none of the 378 women in this report had been routinely screened antenataly for domestic violence.
The highest incidence of domestic violence occurs in women between the ages of 20 and 24 years (Department of Health 2000). With domestic violence being the leading cause of death for women aged 15 to 44 years (World Health Organization 1997). A point worth consideration is that women at the highest risk of domestic violence are in the age range of 20 to 24 years so are therefore at the pinnacle age for pregnancy and childbirth.
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Indicators of domestic violence in pregnancy are expansive and include the following -:
. Late antenatal booking.
2. Poor attendance, repeat attendance for minor trivial or none existent complaints, repeat presentation with depression, anxiety or self-harm.
3. Minimalisation of signs of violence on the body.
4. Poor obstetric history.
5. Unexplained admissions to hospital.
6. Self discharge from hospital, poor compliance with treatment regimes.
7. Constant presence of partner/husband at examinations who may answer questions for her or be unwilling to leave the room, evasion or reluctance to speak in front of or disagree with her partner (CEMD 1997 - 1999).
The pregnancy outcomes for women experiencing violence in the home demonstrate an increase in the incidence of miscarriage, stillbirth, prematurity and low birth weight. Other significant factors include gynecological problems such as vaginal or urinary tract infections and removal of perineal sutures by the perpetrator to enable sexual intercourse (Royal College of Midwives 1997).
Abuse can affect the fetus both directly and indirectly. Stress can affect the baby's size but may in particular reduce the size of the head (Lou 1994). Physical injuries to fetuses, including bruising, broken bones, stab wounds and death may also happen (Morey 1981). This crime is known as feticide and third parties responsible for the criminal or negligent destruction of fetuses are criminally liable. Civil courts can bring claims for injuries
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inflicted before birth if the child survives and is born alive, but these claims are rarely brought before court. In Britain until recently, a charge of murder or manslaughter could not be brought in such cases as the victim was not a
"person in being" at the time of the act. A recent court of appeal judgment has reversed this view ruling that in a case of a man convicted of manslaughter of his heavily pregnant wife whose baby was born alive but died shortly after was considered to be liable (Attorney general 1995). The court judgment stated for the purposes of the 1957 Homicide Act a fetus should be regarded as an extension of the mother. In criminal law an unborn child is specifically protected by the Infant Life Preservation Act (1929). This statute makes it a criminal offense for any person who, with intent to destroy the life of a child capable of being born alive, by any willful act causes a child to die before it has an existence independent of its mother. There is a defense if the act, which caused the death of the child, was done in good faith for the purposes only of preserving the life of the mother. In civil law, the rights of the child are protected by the Congenital Disabilities (Civil Liability) Act (1976). This Act gives a right of action to the baby who is born alive but disabled as a result of an occurrence before its birth, which affected either parent in having a healthy baby or affected the mother or the child during the pregnancy.
Poverty and social class is an area which has been ardently considered as a cause of domestic violence towards women, however both violent men and abused women come from all sorts of social, educational and ethnic backgrounds (Hunt & Martin 2001). Indeed there is no typical stereotype and all women can be at risk. It is a common belief that domestic violence is
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more prevalent among families from lower socioeconomic groups, with much of the research being confined to this group. However studies on domestic violence and poverty indicate that there is not a relationship
between the two factors, although poverty can be a contributory or an exacerbating factor (Department of Health 2000). Whilst lower socioeconomic groups have the highest reporting rate of domestic violence, there may be differences in the rates of reporting. This may emanate from the fact that poorer women have no alternative than to seek assistance and support from police and refuges. It is thought that women from middle class backgrounds may have the resources and support networks to make greater choices in a violent relationship. This may give rise to a greater choice on whether to leave or stay. The reverse can apply however, with women from middle class backgrounds forced into silence due to the supposition that middle class men do not beat their wives (Hester, Kelly & Radford 1995).
A study by Mooney (1993) discovered that 30% of women had experienced violence (more severe than being pushed or shaken) by a current or former partner. In addition 23% had been raped, 27% had been threatened and 37% had been subjected to mental cruelty. Only negligible differences were found relating to class and ethnicity.
Other points worth consideration are that Gielen et al (1994) found that better educated women may be at a higher risk of domestic violence, as the knowledge they posses may redress the balance of power within the relationship and bolster the mans self esteem and control (Gelles & Cornell
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990). Campell et al (1993) proposed four categories of domestic violence in pregnancy highlighting the wide variety of potential causes, they include-:
. Jealousy towards the unborn child,
2. Pregnancy specific violence, not directed at the child,
3. "Business as usual".
Consideration also needs to be given to research within this very sensitive area. There is increased pressure on health care professionals to increase their research base in order to improve practice (Department of Health 1993). According to Hicks (1992) there are several considerations when carrying out research. Incorporated in these considerations are the issues of consent, honesty, promotion of dignity, confidentiality and privacy, approval from ethical committees or involved organizations, advice from experienced independent others, honesty, openness, prevention of compromise or danger and ensuring participants are aware they can withdraw at any time. It is clear that research is essential to improve midwifery practice. However, the researcher should always attempt to ensure that carrying out research would not create greater evils than it will solve.
There is a wealth of information and theory surrounding the reasons why men are violent towards women. However it appears that there is no definite conclusive reason or cause. The author has in this chapter, endeavored to set the scene and provide the reader with a broad synopsis of both domestic violence in general and during pregnancy. Attempting to find the cause is complicated and should be approached with caution, as finding it may for some people, legitimize the act of violence. Attempting to find the cause
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may indeed appear to be a fruitless task, which gives few answers, therefore energy, money, research and time of health care professionals should be spent in an attempt to promote change and improve services for victims of
violence. A final consideration is that domestic violence takes many forms and is a crime where one individual exercises power over another. This behavior is unacceptable to women in general as well as those who are pregnant and should be challenged at every opportunity.
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Chapter Two - Domestic Violence and The Midwives Role
The next chapter will consider the role of the midwife in relation to domestic violence. How the midwife can use her role in both a positive and negative way will be examined. Questioning women about domestic violence and using policies and protocols as a method of support will be carefully considered. The view of the government on subject of domestic violence and education of health care providers will also be taken into account.
In order that the midwife can act as an advocate and empower abused women, it is essential that she must have the correct knowledge. Until recently less was said about domestic violence in relation to health care. Indeed the author can recall no education within this area being provided as a student nurse, with the subject being largely unspoken about. During her midwifery education, which commenced in early 2000 the subject was touched upon in the form of one two-hour educational session. After qualifying as a midwife the author chose to attend a study day on domestic violence and maternal health. This study day was available to midwives within six National Health Service Trusts, places were given on a first come first served basis, and the study day was not mandatory. The literature review within this study clearly illustrates that many midwives feel ill prepared for screening and supporting women suffering from domestic violence. Lack of funding and finances within this area may in some way be responsible for this.
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The government is now striving to raise awareness about the subject of domestic violence, within health care settings, with the production of documents such a "Living Without Fear" (1999). This document is aimed at service providers both in local government, the voluntary sector and also at women themselves. The document aims to provide comprehensive information about violence against women. The issues, which are addressed, are how the violence is being tackled, pulling together examples of good work already in progress, as well as setting a strategic framework for the future. "Living Without Fear" aims to disseminate to those at the sharp end of the spectrum, practical intervention, ideas, contacts and to secure consistent and effective help and information for female victims of domestic violence across the country. The approach used is to provide timely support and protection, bring perpetrators of violence to justice and to prevent violence. Included is six million pounds worth of funding for projects to reduce crime against women. Proposals for a new twenty four-hour help line for women, six point three million pounds towards victim's support and to assist in legal fees has also been allocated.
Yvette Cooper, The Parliamentary Undersecretary of State for Public Health has forwarded a document specifically for health care providers, Domestic Violence: A Resource Manual for Health Care Professionals (Department of Health 2000). This literature places particular emphasis on allocating resources to the National Health Service for education and training within the area of domestic violence. Reassuringly the document acknowledges
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that whilst some basic training and education requirements are available across health care specialties, there are also distinctive needs in respect of
particular skills and knowledge required in specific areas. This is particularly relevant within maternity settings and is applicable to the specific nature of antenatal booking history. The Confidential Enquiry into Maternal Death (1997-1999), unequivocally recommended that sensitive enquiry about domestic violence should be included when routinely taking a booking history and it appears specifics surrounding this particular scenario have been taken into account within the Resource Manual For Health Care Professionals.
Resources are clearly being allocated to this specific area within the author's own clinical setting. Funding has been provided for the appointment of a specialist midwife for domestic violence. A job description for this specialist post can be seen in appendix 2. The midwife in question is actively raising awareness within the clinical area on the subject of domestic violence, by providing teaching sessions and work shops for midwives. She is also liasing with many other multidisciplinary agencies to improve support and services for victims of abuse within the area. At present the specialist midwife is in the process of formulating a policy/protocol for screening for domestic violence within this trust. Clearly protocols and policies is a subject of great importance within the area of domestic violence. For this reason the subject will be explored in more depth later.
The question on the lips of most midwives is, " How do I ask? ". Indeed this is a common worry within the author's own clinical area. For the purpose of
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this study, the author has asked many midwives with varying years of experience within her own clinical area, how they feel about asking women
about domestic violence. Replies have been varied, but many midwives acknowledge this as part of their role. Only a small number of midwives felt this subject was considered to be out of their sphere of practice. The literature review within this study clearly shows that women experiencing violence want to be asked about it and those not experiencing violence clearly do not mind being asked. Some writers however such as Hehir (1998) and Kent (1987) feel quite strongly that midwives should not snoop and may be abusing their position if they do so. Hehir states that if health care workers want to become involved in social issues, that they could perhaps publicize the desperate need of so many mothers for adequate housing, transport and nursery provision. This however, is precisely why midwives are instrumental in the role of screening for violence, as they may be able to provide support, information and assistance for women requiring these services. The Royal College of Midwives (RCM 1997) suggests the following initial questions -:
Is everything all right at home?
How are you feeling?
Are you getting the support you need at home?
Paluzzi & Slattery (1996) favour a more direct approach -:
How do you and your partner resolve conflict?
Bewley et al (1997) suggests in the Royal College of Obstetricians & Gynaecologists publication "Violence against Women" twelve different approaches, five of which listed below -:
Do you ever feel afraid of your partner?
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Does your partner ever treat you badly, such as shout at you, call you names, push you around or threaten you?
Have your ever been in a relationship were you have been hit, punched or hurt in any way? Is this happening now?
We all have arguments at home. What happens when you argue?
Some women tell me that their partners are cruel, sometimes emotionally and sometimes physically hurting them. Is this happening to you?
Questioning within the area of domestic violence is precarious for a midwife without the support of, education and protocols and should be avoided until the midwife has the acquired requisite knowledge and skills.
Midwives are in a unique position when supporting sufferers of domestic violence, as almost all pregnant women will access the services of a midwife at some time during their pregnancy. The most important contribution that a midwife can make is to acknowledge that the abuse is happening (Price & Baird 2001). Hunt & Martin (2002) describe The Empowerment Wheel (see appendix 3). The wheel is in sections with the intention being that each section will interact, assisting women through to empowerment, being supported by the advocacy of the midwife. The wheel suggests that the midwife can support the woman in the following ways -:
Respecting confidentiality, privacy views and wishes. Not talking in front of family members. Acknowledging the woman's right to decline discussion or action even if this may seem logical to the midwife.
Believing and validating her experiences, accepting that sometimes they may need to do nothing, just simply listen.
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Acknowledging the injustice, stating clearly it is not the woman's fault, supporting her decisions.
Respect autonomy.
Helping her to plan for her future safety.
Promoting access to community services.
The reverse approach is demonstrated in the Power and Control Wheel (see appendix 4). This shows how a midwife can use her position in a powerful way, which may be more dangerous for the woman. The wheel suggests that the midwife can fail to support the woman in the following ways -:
Violating confidentiality.
Trivializing and minimizing abuse.
Blaming her.
Not respecting her autonomy.
Ignoring her need for safety.
Normalizing victimization.
The biggest obstacle for midwives may be that they are used to actively "doing something" to improve situations for women in their care, when actively doing nothing, except listening may be the correct approach at that particular time. Midwives who approach the subject negatively may do so as a result of their own deep seated feelings or personal beliefs and experiences. It is important for this reason that midwives examine their own feelings about the subject, and seek advice from a supervisor of midwives or another wise and trusted advisor should they experience obstacles when practicing within this very sensitive area.
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It is important at this point to mention the subject of child protection. There is clear evidence of a relationship between domestic violence and child
abuse. Connors et al (1992) demonstrates that the lowest rates of child abuse are among parents who do not hit each other, with high violence-prone husband and wives the most likely child abusers. This poses a very difficult situation for the midwife, but a situation, which is very clear within the law. Dimond (1994) states that where the midwife has reasonable cause to suspect that a child in the family is being abused she must take appropriate action, despite issues of confidentiality. This is one of the few times when it is considered admissible to breach confidentiality. The Nursing and Midwifery Council (NMC 2002) clause 5.3 states that disclosing information were a client withholds consent is justified in the interests of the public, usually where disclosure is essential to protect a patient, client or someone else from significant harm. Clause 5.4 states that where there is an issue of child protection, a midwife must act at all times in accordance with national and local policies. Such information could be passed on to the appropriate authorities without the midwife being concerned about accusations of breach of confidentiality by the parents. Midwives should of course be open about their intentions to disclose such information or else risk loosing the woman's trust completely. It is recommended that the midwife requests assistance and support from a supervisor of midwives immediately that she suspects child abuse.
Documentation is also essential not just within the area of child protection but within the whole domestic violence forum. All records should be factual, accurate, consistent, written as soon as possible after the event has
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occurred, written clearly with alterations and additions dated timed and signed. It is important to avoid speculation, opinion, judgmental comments,
subjective statements, jargon and abbreviations (Hunt & Martin 2001). The need for evidence, particularly when an abused woman may seek to obtain protection through an injunction or court order is essential. Involving the victim of abuse in this documentation may be useful, enabling her to see what is documented may be instrumental in building a relationship of trust.
An important point worth consideration is that of the use of protocols, which may incorporate guidance on documentation, to direct the midwife. Protocols can be used as a tool of support for the midwife, when working with sufferers of domestic violence and are important to safe and consistent practice. Indeed the author feels that midwives would not practice midwifery care in areas such as pregnancy-induced hypertension, shoulder dystocia, or gestational diabetes without referring to and following trust protocols explicitly. Smith et al (1992) highlight the key role of managers and policy makers pointing out that while health authorities may not be able to prevent domestic abuse, they must acknowledge the problem, providing victims with appropriate help and facilitating secondary and tertiary intervention. Langley (1997) suggests that there is a lack of training in the issues surrounding domestic violence for all health professionals. Langley also suggests that lack of clear protocols for dealing with the subject lie at the root of the failure, of many health service providers to identify, document, and offer appropriate women-centered intervention to women experiencing abuse. Bewley (2001) believes that the following conditions
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are required in order to provide effective protocols on domestic violence for midwives -:
* Ensure effective actions and outcomes based on common understanding of terms and instructions.
* Should be multi and interdisciplinary in drawing up and in use.
* Be based on research.
* Take into account Codes and Rules of Conduct i.e. Royal College of Midwifery, Royal College of Obstetricians and Gynaecologists, Guidelines for best practice, Government reports such as the Confidential Enquiry into Maternal Deaths.
* Should be evidence based.
* Should take into account areas for potential litigation, negligence, and breach of duty of care, breach of confidentiality.
* Should ensure effective staff development and support needs.
The author believes that women will benefit if the same terminology and definitions are used in relation to domestic violence and when formulating protocols. This should provide consistency, improve clarity and ensure that midwives are working in the same way and are well equipped to deal with a yes response received from a victim of domestic violence. A protocol for midwives, which is used in a local National Health Service Trust can be seen in appendix 5.
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Chapter Three - Conclusion and Recommendations for Change.
In conclusion the author would like to make some recommendations for change in practice on the subject of pregnancy and domestic violence. The list of issues within this subject is far too expansive to cover in a study of this size, the author has however, attempted to cover most areas, especially those specific to childbirth and midwifery.
Clearly, there are barriers to screening for domestic violence within a midwifery setting. These barriers include staff apathy, lack of education, lack of funding and resources. Lack of education for midwives, being the main cause of reluctance to screen women. Despite this, research within the topic shows that most midwives are receptive to education on the subject, and most women do not mind being asked about domestic violence. The author believes that midwives have both a moral and ethical obligation to seek education on the subject in order to provide holistic midwifery care, this is highlighted within the Nursing and Midwifery Code of Conduct.
Mandatory training within the subject is something that would be beneficial for both midwives and pregnant women. Midwives receive mandatory training on subjects such as adult and neonatal resuscitation as this is considered to be important to save life. The author believes that this study clearly demonstrates that domestic violence is life threatening to the mother, the fetus and to existing children and should therefore be acknowledged with the same level of importance. Mandatory training and education, both pre
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and post registration is something that the author would be reassured to see in the near future.
Despite exploring at length, the reasons for domestic violence such as biology, genetics, brain dysfunction etc. there appears to be no definite conclusive reason for violence against women. For this reason, the author recommends that midwives do not focus simply on the causes as they do not, legitimize the act of violence, or change the outcome. Midwives should seek to make education, excellence in practice and support of women their main priority.
The role of the specialist midwife for domestic violence has been instrumental in the author's own workplace in helping midwives evolve within the subject. Midwives within the Trust are gradually becoming more receptive to the needs of domestic violence sufferers and also more responsive to provision of education within this area with an increase in the uptake of workshops provided for staff. Clearly this is not a subject that midwives can embark upon lightly or in isolation, and for this reason, the author recommends that midwives acknowledge their limitations and seek supervisory support if necessary.
The author suggests that amalgamation of trust policy within the area would be of benefit to women. If all trusts within the area liased and worked together in the formation of a North West Trust policy for domestic violence, all practitioners would then be sharing the same vision. This would
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surely provide consistency for women and midwives therefore improving care.
The author believes that the way forward is by using a multi-agency approach, avoiding practice in isolation. This approach would include mandatory education for both student midwives and midwives, which would be flexible. Domestic violence protocols and the appointment of specialist midwives would also be essential. Clearly defined support systems for staff is also a necessity.
The word midwife means "with woman", Some midwives may believe, despite educational and supervisory support, that their role is simply to support women through the physiological processes of childbirth. Midwives who do not acknowledge that their role is also to support women through the psychological processes, need to question their reasons for entering the profession of midwifery and question the reasons for their own beliefs.
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References
Attorney General (1995). Death After Antenatal Injury Can Be Murder. T.L.R.
Bacchus, L Bewley, S and Mezey, G (2002). Women's Perceptions and Expieriences of Routine Enquiry For Domestic Violence in a Maternity Service. British Journal of Obstetrics and Gynaecology 109, pp9-16.
Bewley, C (2001). Domestic Abuse and Pregnancy: Writing Policies and Protocols. MIDIRS Midwifery Digest. 11: 2.
Bewley, C and Gibb, A. (2001). Domestic Abuse and Pregnancy: Writing Policies and Protocols. M.I.D.I.R.S. Midwifery Digest, 11:2.
Bewley, S. Friend, J and Mezey, G (eds) (1997). Violence Against Women. Royal College of Obstetricians and Gynaecologists. London.
Bewley,S and Mezey, G (1997). Domestic Violence and Pregnancy. British Journal of Obstetrics and Gynaecology , 104 : 528-531.
Bourlet, A. (1990). Police Intervention in Marital Violence. Open University Press. Milton Keynes.
Brewer, E, C. (1978). The Dictionary of Phrase and Fable. Avenal Books. New York.
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Brown, J. K and Kerns, V (1985). In Her Prime : A New View of Middle Aged Women. Bergin and Garvey. Massachusetts.
Campell, J. C Oliver, C Bullock, L (1993). Why Battering During Pregnancy? Clinical Issues in Perinatal and Women's Health Nursing. 4: 343-349.
Congenital Disabilities (Civil Liability) Act 1976.
Connor, K.A Heiser, L and Trickett, P (1992). CAPINEX: Abstract descriptors. Journal of Family Violence. No 4, pp321-334.
D.O.H. (1993) Department of Health. Report of The Task Force on the Strategy for Research in Nursing and Midwifery and Health Visiting. Department of Health.
D'Avolio, D Hawkins, J.W. and Haggerty, L.A (2001). Health Care For Women International, vol 22, no 4, pp349-62.
De Beauvoir, S. (1952/1974). The Second Sex. Penguine. Harmondsworth.
Department of Health (2000). Domestic Violence: A Resource Manual for Health Care Professionals. Department of Health, London.
9699564
Dimond, B (1994). The Legal Aspects of Midwifery. Books for Midwives Press. Cheshire.
Dobash, R.E and Dobase, R. (1980). Violence Against Wives: A Case Against Patriarchy. Open Books. Shepton Mallet.
Elias, M (1981). Serum Cortisol, Testosterone, and Testosterone Binding Globulin Responses to Competitive Fighting in Human Males. Aggressive Behavior, 7, 215-224.
Fearns, B. (1988). Cited in : Good Practice When Working With Victims of Violence. Jessica Kingsley Publishers. London.
Gazmararian, J.A Lazorick, A Spitz, A.M Ballard, T.J Saltzman, L Marks, J.S (1996). Prevalence of Violence against Pregnant Women. J.A.M.A. 275 : 1915-1920.
Gelles, R Cornell, C.P (1990). Intimate Violence in Families. Sage Publications. California.
Gielen, A. C O'Campo, P.J Faden, R.R Kass, N, E Xue, X (1994). Interpersonal Conflict and Physical Violence During The Childbearing Year. Social Science and Medicine. 39: 781-787.
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Greene, A. F Coles, C.J and Johnson, E. H (1994).Psychopathology and Anger in Interpersonal Violence Offenders. Journal of Clinical Psychology, 50, 906-912.
Haraway, M and O'Neil, J.M (1997). A Multivariate Model Explaining Men's Violence Toward Women : Predisposing and Triggering Hypotheses. Violence against Women, 3 (2), 182-203.
Haraway, M and O'Neil, J.M (1999). What Causes Men's Violence Against Women? Sage Publications. London.
Hehir, B (1998). The Pregnancy Police. LM, pp8-9.
Hester, M Kelly, L and Radford, J (eds) (1996). Women, Violence and Male Power. Open University Press. Buckingham.
Hicks, C. M (1992). Research in Midwifery : Are Midwives Their Own Worst Enemies? Midwifery. 8, 12-18.
Home Office/Cabinet Office (1999). Living Without Fear : An Integrated Approach to Tackling Violence Against Women.
Hunt , S. C. and Martin, A. M. (2001). Pregnant Women Violent Men : What Midwives Need To Know. Books For Midwives. Oxford.
Infant Life Preservation Act 1929.
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Kent, A (1987). Home is Where The Fear Is. Nursing Times. No85, pp16-17.
Langley, H (1997). An Overview. In: Bewley, S Friend, J and Mezey, G eds. Violence Against Women. RCOG Press. London.
Linnoila, M Virkkunen, M Scheinin, M Nuutila, A Rimon,R and Goodwin, F. K (1983). Low Cerebrospinal Fluid 5- Hydroxyindoleacetic Acid Concentration Differentiates Impulsive From None Impulsive Behavior. Life Sciences, 33, 2609-2614.
Lou, H. C (1994). Prenatal Stressors of Human Life Affect Brain Development. Developmental Medicine and Child Neurology. 36 : 826-832.
Mazur, A and Lamb, T. (1980). Testosterone, Status and Mood In Human Males. Hormones and Behaviour, 14, 236-246.
Mednick, S. A Gabrielli, W. F and Hutchings, B (1984). Genetic Influences in Criminal Convictions : Evidence From An Adoption Cohort. Science, 224, 891-894.
Mooney, J (1993). The Hidden Figure : The North London Domestic Violence Survey. Middlesex University Center for Criminology.
Morey, M (1981). Profile of A Battered Fetus. Lancet, 1295.
9699564
N.M.C. (2002). Code of Professional Conduct. Nursing and Midwifery Council, London.
N.S.P.C.C. (2002). Domestic Violence Gives Warning Of Child Abuse. National Society for Prevention of Cruelty to Children. www.nspcc.org.uk
Oyster, C, K. Hanten, W, P and Llorens, L A. (1987). Introduction to Research: A Guide for The Health Service Professional, J. B. Lippincott Company, London.
Paluzzi, P. A and Slattery, L (1996). No Woman Deserves To Hurt. Domestic Violence Education For Women Health Care Providers. American College of Nurse Midwives. U.S.A.
Pizzey, E (1974). Scream Quietly or The Neighbours Will Hear. 1st Edition. Penguin Books. Middlesex.
Polgar, S and Thomas, S.A. (1995). Introduction to Research in The Health Sciences, 3rd Edition, Churchill Livingstone, London.
Price, S and Baird, K (2001). Domestic Violence in Pregnancy. Practicing Midwife. 4 (7) : 12-14.
Price, S. (2001). Domestic Violence In Pregnancy. In: Squire, C (ed). The Social Context of Birth. (awaiting Publication).
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R.C.M. (1997). Royal College of Midwives. Domestic Abuse in Pregnancy, Position Paper 19. Royal College of Midwives. London.
Raine, A (1993). The Psychopathology of Crime : Clinical Behaviour as A Clinical Disorder. Academic Press. California.
Raine, A (1993). The Psychopathology of Crime : Criminal Behavior as a Clinical Disorder. Academic Press. California.
Rees, C. (1997). An Introduction to Research for Midwives, 1st Edition, Books for Midwives Press, Cheshire.
Rose, R Bernstein, I and Gordon, T (1975). Consequences of Social Medicine, 37, 50-61.
Conflict on Plasma Testosterone Levels in Rhesus Monkeys. Psychosomatic Scobie, J and McGuire, M. (1999). The Silent Enemy: Domestic Violence in Pregnancy. British Journal of Midwifery, vol. 7, no 4.
Smith, S Baker, B and Buchan, A (1992). Adult Domestic Violence. Health Trends. 24 (3): 97-99.
Stanko, E. A. Crisp D, Hale C, Lucraft, H (1998). Counting The Costs : Estimating The Impact Of Domestic Violence in The London Borough of Hackney. Crime Concern. Swindon, Wiltshire.
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Steen, M. (2000). Developing Midwifery Responses to women in their Care Who are Living with Violent Men. M.I.D.I.R.S. Midwifery Digest, 10: 3 pp313-317.
Stenson, K, Saarinen, H, Heimer, G and Sidenvall, B. (2001). Women's Attitudes to Being Asked About Exposure to Domestic Violence. Midwifery, 17, 2-10.
Svare, B and Kinsley, C.H (1987). Hormones and Sex Related Behavior. In K. Kelley (Ed.), Females Males and Sexuality : Theories and Research, pp13 58. State University of New York Press. Albany.
Taylor-Brown, J (2001). What Works in Reducing Domestic Violence? A Comprehensive Guide For Professionals. Whiting and Birch Ltd. London.
The Empowerment Wheel/Power and Control Wheel. Domestic Abuse Intervention Project. USA. In: Hunt,S. C and Martin, A.M (2001). Pregnant Women, Violent Men: What Midwives Need To Know. Books for Midwives Press. Oxford.
The National Institute for Clinical Excellence, The Scottish Executive Health Department, The Department of Health Social Services and Public Safety: Northern Ireland (1997-1999). Why Mothers Die. Midwifery Summary and Key Recommendations. The Confidential Enquiry into Maternal Death in athe United Kingdom.
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Volvaka, J (1995). Neurobiology of Violence. American Psychiatric Press. Washington.
W.H.O. (1997) World Health Organization. Violence Against Women. A Priority Health Issue : What Health Care Workers Can Do. W.H.O. Geneva.
Walters, G. D (1992). A Meta-Analysis of The Gene Crime Relationship. Criminology, 30, 595-613.
Williamson, E. (2000). Domestic Violence and Health: The Response of The Medical Profession. The Policy Press, Bristol.
Women's Aid Federation (1997) cited in Pregnant Women Violent Men : What Midwives Need To Know. Books For Midwives. Oxford.
Appendix one.
Appendix Two.
Appendix Three.
Appendix Four.
Appendix Five.
Special thanks to Sheila Murray - Specialist Midwife for Domestic Violence for all the information and support given for the purpose of this study.
Thanks to Sue Baines - Midwifery Tutor for her educational guidance and support.
Thanks also to Gill Barnes and Tracey Hewlett for their proof reading, positive criticism, friendship and support.
Finally thanks to Steve for his patience, willingness, and understanding.
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