Screening
Women often remark that they want to be asked and
that they would not have disclosed otherwise for many
reasons including: fear of not being believed, fear
that their children will be taken away, fear of worsening
violence once outsiders are involved, embarrassment
about what is happening to them and lack of awareness
that help can be obtained from health care professionals.
Some women have further barriers to disclosure such
as language and culture.
Routine enquiry increases detection and is acceptable
to women ( 1).
Antenatal care provides an opportunity for repeated
enquiry, which may further increase detection. However
routine enquiry must only be introduced with a robust
policy for referral and training and support for those
involved in screening in conjunction with local groups
working in this area. Inappropriate responses or
advice from health care professionals can worsen the
situation. In addition, those asking the question may
have been victims of domestic violence themselves and
find the prospect of discussing it with another individual
difficult.
What can we do?
In the absence of a comprehensive screening programme
with support, there is still much that can be done
as an individual. As health care professionals we are
trained to identify problems and to solve them. This
is not usually possible in domestic violence but it
is our responsibility to help women identify and acknowledge
abuse, provide appropriate referral and on going support.
Be aware of the presentation
Provide privacy – ideally all women
should be seen alone at least once during their pregnancy
Provide interpreters if appropriate- do not
rely on family members
Do listen, be supportive and non- judgemental- women
need to be believed Be aware of appropriate referral – women’s
aid provide advice for professionals as well as women
themselves Recognise your limitations – ask for advice
Explain the limitations of confidentiality- under
the child protection act, social services must be
alerted if there is any concern regarding the safety
of children in the home. This must be explained to
the woman.
Do not give directive advice or try and solve the
problem Do not encourage her to leave – a woman is
most at risk of serious abuse or even death when
she leaves or prepares to leave (2)
If she is thinking of leaving, help with appropriate
referral and a check list of things she may need, birth
certificates, keys, national insurance number,
visa, passport, telephone numbers, toiletries,
clothes
Do not confront the partner
Safety is paramount- this includes your safety
and that of the woman’s children
Do not document in the hand-held notes
If consent for documentation is given it should
be in hospital or GP records that are not accessible
to the perpetrator – for example notes should
not be given to women to carry to scan appointments
within the hospital
Careful detailed documentation may be used as evidence
in later legal action
Offer referral for legal advice- family lawyers
may provide advice free of charge or have links via
local agencies. Part IV of the family law act 1996
includes occupation orders, which concern
the right to occupy the family home and non-molestation
orders, which provide protection against violence
and abuse. Health care professionals should not give legal
advice but refer.
Do not be despondent if she chooses not to leave – there
are many complex reasons for this, she needs ongoing
support whatever she decides to do
Asking the question
When the above criteria have been met it is appropriate
to explain why you are asking the question. For example:
“ I am sorry if someone has already asked you about
this and I don’t wish to cause you any offence, but
we know that throughout the country 1 in 4 women experiences
violence at home at some time during their life. I
noticed that you have a number of bruises/cuts/burns
(as appropriate).” ( 3)
It is then appropriate to ask direct questions, for
example:
Do you ever feel frightened by your partner, or other
people at home?
Have you ever been slapped, kicked or punched by your
partner?
Your partner seems very concerned and anxious about
you. Sometimes people react like that when they feel
guilty, was he responsible for your injuries?
These are suggestions adapted from the Department
of Health manual, see below. They are not a comprehensive
list and each situation will demand slightly different
questions. A more detailed assessment tool, the Abuse
Assessment Screen has been used successfully in the
antenatal setting to improve detection rates (4, 5). Questions
must be asked with the appropriate referral advice
available- see above.
Further advice for Professionals:
Department of Health Domestic Violence: Resource Manual
for Health Care Professionals.
Free copies available at www.doh.gov.uk/domestic.htm or
DH Publications
PO Box 777
London
SE1 6XH
References
1. Mezey G, Bacchus L, Haworth A, Bewley S. 2000.
An exploration of the prevalence, nature and effect
of domestic violence in pregnancy. ESRC study. www.rhbnc.ac.uk/sociopolitical-science/vrp/
2. Manmer J, Itzin C. (2000). Home Truths About Domestic
Violence: feminist influences on policy and practice.
London: Routledge.
3. Camden Multi-Agency Domestic Violence Forum. Domestic
Violence: a training pack for health profseeionals.
4. McFarlane J, Parker B. (1994) Abuse during pregnancy:
A protocol for prevention and intervention. New York:
March or Dimes Birth Defects Foundation.
5. Norton L B, Jefferey F P, Zierler S Lima B, Hume
L. Battering in pregnancy: an assessment of two screening
methods. Obstet Gynecol 1995; 85(3): 321-325, Abstract
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