Domestic Violence during Pregnancy: The role of Midwifery and Screening in the North of Italy

Review article

Domestic Violence during Pregnancy: The role of Midwifery and Screening in the North of Italy

Corresponding authorL.Driul, Department of Gynecology, University of Udine, Udine, Italy, Email:lorenza.driul@uniud.it

Abstract

Objective

To explore violence against women during pregnancy.

Design

Observational and interview data were collected using checklist and interview guide

Setting

The study was carried out in maternity clinics in north-east of Italy (Friuli-Venezia Giulia) and in Trentino Alto Adige. It involved
all midwives active in the selected centers.Participants

This study involved all midwives active in the selected centers.Measurements and findings

A questionnaire was used for data collection, after the approval of the respective health care companies. 197 midwives answered the questionnaire.

The most of the midwives (62.2%) have met, in their practice, women who were involved in domestic violence during pregnancy. Midwives think screening could be effective to detect domestic violence (86.2%), in their opinion it should be conducted by a multidisciplinary team in form of interview.

Conclusion and implication for practice
Midwives consider they don’t have enough knowledge about the subject (88.8%) but show interest in specific training, in order to improve their practice and to help women. This study shows the evidence of the need of specific training for midwives at University and screening for domestic violence in pregnancy.
Introduction

Domestic violence is defined by the World Health Organization (WHO) as “any behavior within a relationship that causes physical, psychological or sexual abuse to those who are in that relationship” [1].

Domestic violence is present in the lives of many women; it damages their health and their children and is a major cost to society. This phenomenon is largely hidden, therefore difficult to study [2].

Between 2000 and 2013 in Italy there are 2,399 women victims of murder: 1,692 of them were killed within the family context (70.5%) [3].

In Italy the severity of the problem of violence against women is increasing and it is urgent for health professionals to identify it.The purpose of this study was to evaluate the experience of the midwife in two regions in the North of Italy (Friuli Venezia Giulia and Trentino Alto Adige), during the course of professional practice, with respect to the recognition of the phenomenon of domestic violence in pregnancy. Another objective was to assess which are the basic knowledges of midwives on this topic and the possible inclusion of screening to be offered in pregnancy.

MethodsThe study was conducted from 2014 to 2015 at the different Clinic of Obstetrics and Gynecology of Friuli Venezia Giulia and Trentino Alto-Adige, coordinated by the Department of Obstetrics Gynecology Hospital University of Udine and the Degree Course in Midwifery of Udine, University of Udine.

The study was authorized by the respective Health Departments in the hospitals of reference.
Were recruited after informing about the purpose of the investigation and informed consent, midwives working in the period of the survey at the previously mentioned Clinics of Obstetrics and Gynecology. The instrument used to conduct the survey consisted of an anonymous questionnaire, drafted in July 2014, consisting of 19 multiple choice questions: 15 questions concerned the specific investigation of the midwife experience, knowledge, opinions about the screening, adequate training on the subject and 4 items were intended to preliminary describe the personal qualities of the participant: gender, type of training, years of professional practice and service where they worked.
Findings197 midwives (63.7%) have joined this study, returned the completed questionnaire and informed consent, in separate envelopes to anonymity.

The average years of work experience of midwives surveyed was of 15.45 ± 8.2; analysis of data shows that almost half of the midwives who responded to the questionnaire appeared to have up to 10 years of experience.
The 45.9% of midwives had the three-year university degree and the 27.4%.had nursing degree followed by two years of midwifery.
The 62.2% of the midwives who participated in the study had contact with pregnant women victims of violence and an even higher percentage (75.6%) had suspected, at least in one occasion, that some of their assisted were affected by this problem (Table 1).
Table 1.

Midwives have indicated in 61.5% of cases at least two suspicious presence of domestic violence in the lives of their patients: association with this most frequently found to be the behavior of the patient herself and the behavior of her partner / husband.

In 18.6% midwives have suspected violence by a single signal, in most cases (63.7%) had at least two signals associated.

The 63.1% midwives believed that prevalence of domestic violence in pregnancy is less than 10%. The midwives have identified
as risk factors for domestic violence during pregnancy in 69.6% of cases: low socioeconomic status, substance abuse and a state of economic dependence. (Table 2)
Table 2.
The midwives think the fetal-maternal consequences were postpartum depression ( 81.5%) and preterm delivery (61.5%). (Table 3)
Table 3.
The 86.2% of midwives appears to be favorable to use a screening test to identify pregnant patient’s victim of domestic violence. Most midwives (88.7%) believe that the vast majority of them should be involved in the implementation of the screening. The reason given most frequently is empathy (35%); a small percentage think that it should occupy only the midwife (10.7%) while the majority believes that the midwife should act within a multidisciplinary team (52%), because it is important to address this issue “to network”(36.7%). (Table 4)
Table 4.
Table 5.

Discussion

Violence against women is a transversal phenomenon, present in all levels of society and in all societies, it transcends geographical and cultural boundaries. The types of measures that States must implement concern several fronts: prevention, protection, prosecution and monitoring. Domestic violence is a phenomenon which is largely hidden and therefore very difficult to study, for this reason is identified as “unknown number”. There are still few European studies on costs of violence, because to maintain them you need to have data on prevalence and incidence, data that begin to be available since only a few years. The lack of this information affects the estimated costs of violence in the Italian context. The international literature [4] do not recommend use of universal screening, but considers screening to be effective only in specific subjects, such as pregnant women. Screening has the great advantage of increasing to seven times the possibility to identify victims of violence, with the consequent possibility of providing information and practical help to these women [5]. The studies in literature [6,7] show that screening is well accepted by the patients: do not feel wounded by the questions, partly because they understand their importance. Screening should be offered at least once in each trimester of pregnancy and once in puerperium. The patient rarely reveal the abuse suffered at the first meeting, it is important to have confidence to be able to talk about this important issue. Screening for violence in pregnancy is often performed in Northern Europe and now new projects are starting in other countries of Europe. The period of pregnancy is considered in literature [8,9]”a window of opportunity”. Many women approach the world of health care only during pregnancy. And regular attendance of the same surgery creates a relationship of trust and confidence, especially with the midwife, who is the key figure. In Italy, the severity of problem of violence against women is becoming important and care protocols are urgent. In this study evaluated the majority of midwives tend to underestimate the phenomenon of violence in pregnancy. In our study, the risk factors for domestic violence in pregnancy which are more often reported in the questionnaire were “low socioeconomic level”, “substance abuse”, “economic dependence of women.” In literature, several studies [10,11] (indicate that the risk factors are very different: previous abuse, unwanted pregnancy or pregnancy at a young age, while substance abuse is strongly related to violence, but not as a cause, rather as a result. In our study midwives indicate “depression in postpartum and “abortion / premature birth”, as the more frequent complications. In literature many studies [11 ] show low birth weight as the most frequent complication.

A very high percentage of midwives (88.8%) feel they are not properly prepared to identify violence during pregnancy and the most of the population in question expresses interest in receiving specific training.

Basic university education should be implemented and specific continuos professional training should be provided. The training should be “tailored to their clinical practice and working environment.” [12] “Midwives need training on how to interact with abused mothers using non-coercive, supportive and empowering mechanisms. Many women may not spontaneously disclose the issues of child or domestic abuse in their lives, but often respond honestly to a sensitively asked question.”[13] It is important also to develop guidelines and specific local protocols.

Conclusion
The most important indication from the data collected was the need for a detailed study of domestic violence in the university training of midwives; adequately trained midwives using shared screening tests on domestic violence would be able in the future to work harder and with greater continuity with the various specialized services in the area.

References

1.WHO, Prevention of violence: a public health priority, 1996. The Forty-ninth World Health Assembly.

2.Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet. 2002, 360(9339): 1083-1088.

3.EU.R.E.S. Social and Economic Research, November 2014, “Second Report on femicide in Italy. Characteristics and trends of 2013”, Rome, Italy.

4.Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partners violence during pregnancy: maternal and neonatal outcomes. J J Womens Health (Larchmt). 2015, 24(1): 100-106.

5.Ramsay J, Richardson J, Carter YH, Davidson LL, Feder G. Should health professionals screen women for domestic violence? Systematic review. BMJ. 2002, 325(7359): 314.

6.Yelland J, Brown SJ. Asking women about mental health and social adversity in pregnancy: results of an australian population- based survey. Birth. 2014, 41(1): 79-87.

7.O’Reilly R, Beale B, Gillies D. Screening and intervention for domestic violence during pregnancy care: a systematic review. Trauma Violence Abuse. 2010, 11(4): 190-201.

8.Finnbogadóttir H, Dykes AK, Wann-Hansson C. Prevalence of domestic violence during pregnancy and related risk factors: a cross-sectional study in southern Sweden. BMC Women’s Health. 2014, 14:63.

9.James L, Brody D, Hamilton Z. Risk factors for domestic violence during pregnancy: a meta-analytic review. Violence Vict. 2013, 28(3): 359-380.

10.Chambliss LR. Intimate partner violence and its implication for pregnancy. Clin Obstet Gynecol. 2008, 51(2): 385-397.

11.Murphy CC, Schei B, Myhr TL, Mont JD. Abuse, a Risk Factor for LBW? A Sistematic Review and Meta-Analysis. CMAJ. 2001, 164(11): 1567-1572.

12.Torres-Vitolas C, Bacchus LJ, Aston G. A comparison of the training needs of maternity and sexual health professionals in a London teaching hospital with regards to routine enquiry for domestic abuse. Public Health. 2010, 124(8): 472-478.

13.Lazenbatt A. Safeguarding children and public health: midwives’ responsibilities. Perspect Public Health. 2010, 130(3):118-126.

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