Summary
Background
In the Government’s Action Plan “Violence in close relations” (2004–2007) the Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS) was given the task to implement a pilot project whereby routine questions should be asked about violence during maternity check-ups. The purpose of the project was to develop methods to uncover violence. The project was to include routines and measures for cooperation and follow-up of any violence that had been discovered.
Different methods for disclosing violence against pregnant women has been tested in a series of studies, and it has been shown that relatively simple assessment tools render reliable results. However, little research has been done on the impact of screening on women’s health and their use of services. Several summaries of existing research have therefore concluded that there is not enough knowledge to either recommend or not recommend that screening is introduced as a permanent part of the antenatal care. Some recent research shows, however, that asking questions about exposure to violence may have a positive effect with regard to reducing occurrence of new cases of violence.
The project was carried out in cooperation with Alternative to Violence (ATV) in Telemark and took place in 4 municipalities in Telemark; Skien, Kragerø, Bamble and Bø. A project coordinator was employed to assist the project. The aim was that midwives in the four municipalities should ask all pregnant women that came for consultation in the trial period questions about exposure to violence.
The project was divided into three phases:
• The first phase consisted of preparation of the project. This included engaging a sufficient number of municipalities to take part in the project, designing and adapting the screening tools and routines that should be tried out, ensuring that those midwives that should carry out the screening had the necessary knowledge to do so in a good way and that that they knew what to do if anyone confirmed that they were victims of violence. Furthermore, follow-up routines for women exposed to violence, their children and if possible also the perpetrator of violence had to be introduced to ensure that they got the follow-up needed. It also had to be ensured that municipalities and other current authorities had the necessary preparedness and competence.
• The second phase consisted of screening and assistance to those exposed to violence, their children and the perpetrators. This included ensuring that the midwives really carried out the screening, that they got support and guidance they needed and that a sufficient number of women were screened. It also had to be ensured that those exposed to violence who wanted and were in need of assistance got the best possible help, that the children were followed up, that perpetrators that were motivated was followed up from ATV and that everything worked in practice.
• The third phase consisted of collecting data and analysing the experiences from the practical trying out. This was based on both quantitative data such as registration forms and written questionnaires that the midwives and the women that had been screened should fill out, on access to journal data from different services who followed those exposed to violence, on qualitative interviews with the midwives and the women exposed to violence and on participating observation in the follow-up work with several of the victimised women.
It was a prerequisite that the midwife should be alone with the woman when she asked about exposure to violence. If the pregnant woman answered yes to the questions about violence or other abuse, the midwife should ask further questions to clarify the situation and in cooperation with the woman consider further follow-up.
Results
The screening was carried out from October 2007 to the end of 2008. In this period approx. 890 pregnant women came for consultation with the midwives in the four municipalities. Of these 451 women, 51% of all, were asked questions about violence. The main reasons why women were not screened were that they did not come alone to consultations, they were immigrants and the translation possibilities were not satisfactory, that the women came to consultation late in the pregnancy, that the midwife felt there was not enough time, it was holiday time, illness or that stress and forgetfulness made the midwife neglect the screening.
Only three of the 451 women refused to answer the screening questions. The women were asked about physical, sexual and emotional violence and abuse, if they were afraid or if they were concerned about the children’s safety. In total, almost ¼ of the women experienced at least one of these strains. The most common type of strain was emotional abuse and control from partner or ex-partner; more than 15% reported this. 2.5% reported that they had been exposed to violence during the last year, and over 7% had been exposed to it earlier. Almost 2% had been exposed to violence during the present pregnancy, near 1% had been victims of sexual abuse while pregnant whereas 4.5% had been exposed to it previously. Those who reported that they had been exposed to some kind of abuse, were also asked if they feared for their children’s safety. Prior to this question the midwife had to inform the woman that she had a duty to report to the child care if she learnt that children were exposed to abuse. Despite the fact that this could have prevented some women from answering, 5% reported that they were concerned about their children’s safety.
Previous studies have pointed out that there seems to be signifcant skepticism among health personnel to screening, based on the belief that the women would perceive this in a negative way. To clarify possibly negative sides with the screening the women were asked to fill out a questionnaire on how they had felt getting questions about violence and what they thought about the information they had received on why they were screened. Of the women who answered, nobody felt that the information was lacking, two felt it was neither good nor bad, the rest was of the opinion that it was good or very good. Two of the women refused to answer how they had experienced the screening, and three reported that they had experienced it as very unpleasant. In addition, 16 women reported that they had experienced it as a little unpleasant. The remaining 92% of the women felt it was ok or very positive to be screened. This corresponds well with findings in previous studies from other countries.
A somewhat higher percentage of the women who themselves had been exposed to violence or other strains felt it unpleasant to be asked. Also among these women, however, a great majority, almost 85%, felt it was ok or very positive to be asked, and only3% felt it was very unpleasant or refused to answer the questions.
Not all the women that reported to the midwife that they were exposed to abuse wanted follow-up from other authorities, some wanted to solve the problem themselves, others would limit the follow-up to contact and talks with the midwife, but not involve others. Some women, however, were referred to the midwife outpatient department at the hospital; some were followed up by the project coordinator and were referred to the district psychiatric centre.
It proved difficult to obtain comprehensive information on what follow-up the women that wanted assistance received from different services. Information from the women exposed to violence, however, indicated that they to a large degree were satisfied with the follow-up, even though some also expressed scepticism and insecurity facing some of the services, especially the child care.
Several midwives were a bit reluctant at first to ask about exposure to violence. They felt that violence still is a taboo and an intimate area to enter, and they were uncertain how to handle a situation where violence was uncovered. Others had no problems from the start. As time went on those who found it difficult at first felt it was easier to raise violence as a topic. The response from the women was predominantly positive, and the midwives experienced that talking about violence also opened up for the pregnant women to tell about other problems and strains they were facing. Several midwives also experienced that the project had led to a closer alliance between them and the pregnant woman. At the same time they also experienced that the knowledge they received could be a burden and that it was emotionally demanding to receive all these histories about life and feel responsible for the individual woman and her situation.
In the project much emphasis was put on ensuring a multi service cooperation to back the midwives and follow up the women exposed to violence. However, this functioned differently in different municipalities. Whereas some municipality midwives as a starting point did not know which persons were working in the different services, others attended regular cooperation meetings in their municipality.
Even though several midwives at the start of the project expressed scepticism and uncertainty regarding asking about violence, this scepticism decreased rapidly when they became familiar with the screening, and at the end of the project the midwives were unambiguously positive to screening.
Conclusion
Our conclusion is that there are good reasons to implement routines asking questions about violence in maternity care. A simple screening procedure seems sufficient to get information on violence, abuse and other strains of great significance both to the woman’s and the unborn child’s health and welfare. The screening can take place with- out great changes in routines and organisation of the care. To be asked questions about exposure to violence by the midwife is well received by the pregnant women. Given that necessary conditions regarding preparations, adjustments and follow-up are met, the midwives are positive to screening. Recent research indicates that screening in itself seems to have a positive effect on women’s exposure to violence, and that good follow-up measures also have effect.
Important prerequisites for the screening to be introduced as a general measure in maternity care are that practical conditions are adapted to this, that health personnel gets adequate training, that arrangements are made for professional support and guidance and that the women exposed to violence are ensured satisfactory follow-up care.