3. MSc in Child Forensic Studies: Psychology and Law
Table of Contents
Acknowledgements Page 4
Declaration Page 5
Abstract Page 6
Introduction Page 7
Historical perspective Domestic Violence Page 9
Depth of Understanding Page 10
Conflicted Emotions Page 11
Child Protection Page 11
Centre for Maternal & Child Death Enquiries Page 12
Intuition Page 13
Psychological Paralyses Page 14
Domestic Violence in Perspective Page 15
Purpose & Rationale for Study Page 15
Aims Page 16
Methodology & Design Page 16
Participants Page 16
Procedure Page 17
Ethics Page 18
Data Analysis Page 18
Results and Discussion Page 19
Overall summary & conclusion Page 26
References Page 28
Acknowledgements:
3
4. I would like to thank my supervisor Dr Julie Cherryman for all her
encouragement, support and eternal optimism. I would like to thank all the
Midwives who gave their precious time and commitment for the study. In
particular a thank you is extended to Tricia Bratby and Gill Slade who was
always willing to ‘read’ my story. Thank you also to Sian who transcribed all
interviews, a long and difficult task, you did a fantastic job.
I would especially like to thank my lovely husband Harvey for his
encouragement, patience, advice and importantly technical support
throughout my course; I am deeply appreciative of you being there. My
three sons Elliot, Daniel and Ciaran, who are now great cooks, know how
to use a washing machine and without whom life would have no joy.
In memory of Helen Hutchinson, an inspiring Midwife and
friend.
4
5. Declaration:
I declare that the research described in this report is purely my own work,
and the report is an original manuscript. All data used in the investigation
was personally collected and was done so following the specified
methodology. In accordance with the University’s policies, my project has
undergone and passed all the necessary ethical approvals. I declare that
such ethical approval was obtained by the Department of Psychology prior
to the conduct of the project.
I declare that my word count is
8235 words
September 13th 2013
5
6. Domestic Abuse and Pregnant Women: Who Cares?
What is the role of the Midwife?
Abstract
Violence against women is a national and global concern, (Devries, Watts, Yoshihama,
Kiss, Schraiber, Deyessa, & Garcia-Moreno, 2011). It is estimated that one in every four
women will face some form of violence in their lifetime (World Health Organization,
2005). Pregnancy can act as a trigger for Domestic Violence (Home Office Definition,
Appendix 6) and abuse or exacerbate an existing problem; this has serious
consequences for maternal and infant health and may lead to potential morbidity and
mortality (Kavanaugh, & Miller, 2012). Subsequently, Midwives are expected to ask
pregnant women by routine confidential enquiry (RCE) about Domestic Violence (DV),
yet many do not. The importance of understanding this reluctance should not be
underestimated as not one life is at stake, but two. This study explores the perceptions,
experiences and attitudes of Midwives asking woman about DV. Five Hospital and five
Community Midwives were recruited via opportunity sampling. These midwives were
individually interviewed using semi-structured interviews which were audio recorded and
transcribed verbatim. From the analysis of the data, three main interrelated themes were
discussed: Environment, the task of asking the question depended on the setting the
Midwives worked in. Consequences, which meant the Midwives acknowledged both
their clinical responsibilities and the physical safety of the mother and baby; despite the
conflicting emotional issues involved. Lastly, experiences, as it was found that Midwives
experienced extreme reactions when asking about DV. Although they expressed desire
to offer support, it was unclear which external resources they could call upon. The
implication of this study concerns the whole maternity environment. Arguably, there is a
need for mandatory DV training involving an awareness of available resources and
regular reflective supervision with psychological support.
6
7. Introduction
It is estimated that one in every four women will face some form of violence in their
lifetime (World Health Organization, 2005). As pregnancy can act as a trigger for
Domestic Abuse or exacerbate an existing problem, the effects of violence against a
pregnant woman can have serious consequences for maternal and infant health, leading
to potential morbidity and mortality (Baird, Salmon & White, 2013). The care of
pregnant victims of violence is significant to all agencies (Williston & Lafreniere,
2013), as it is not only one life which is at stake, but two. Healths practitioners are
primarily clinicians working from a ‘health’ perspective subsequently the forensic
medical responses to domestic violence have - for the most part - been negligible (Nittis,
Hughes, Gray, & Ashton, 2013). This has led to lost opportunities and a failure to
address, document or attribute any causation of injuries to a perpetrator; this leads to
potential evidence not meeting the standards required by court. Although it has
traditionally been considered the duty of the Police and courts to respond to domestic
and sexual violence, relatively few women report violence to the criminal justice system
(Women’s National Coalition, 2009). Whilst it is recognised that women in abusive
relationships can be fearful of disclosing their abuse, Midwives are often the first
healthcare professional a woman will talk to, if asked, in addition Bostock, Plumton,
Pratt (2009) highlight the fact that women do not object to being asked the question,
preferring to have the opportunity to be asked. In the UK, Domestic Abuse has shifted
from being ‘behind closed doors’, into the public arena and is now firmly established as
an important public policy issue (Peckover, 2013). Midwifery policy reflects this as
Midwives are expected to ask about DV, making a ‘Routine Confidential Enquiry’
(RCE). However, some do not feel confident to do so (Salmon Murphy Baird & Price,
2006). Chaplin, Flatley and Smith (2011), reported in 2010/11 (British Crime Statistics)
that there were 392,000 incidents of Domestic Violence and this is - due to under-
reporting - presumed to be a low estimate. Despite such figures, Taylor, Bradbury-
Jones, Kroll, & Duncan, (2013) found some Health Practitioners did not share the same
beliefs about screening for DV, preferring not to open a Pandora’s Box (Henderson,
2001). Understanding such beliefs, reluctance or lack of confidence in asking the
question about DV should not be underestimated. The rationale for asking about DV is
that an intervention may happen early enough to ‘break the cycle’ and prevent inter-
generational abuse, by signposting the expectant mother to the relevant agencies such as
7
8. Women’s Aid; for practical support and often much needed legal advice. This study
aims to explore the ‘real world’ views of local Midwives about their experiences and
attitudes towards DV to seek a deeper understanding of the potential difficulties faced.
8
9. Historical background of Domestic Violence
Domestic violence in pregnancy is not a new phenomenon (Bailey & Giese, 2013).
Three great bodies of thought have influenced Western society’s views and treatment of
women: Judeo-Christian religious ideas (Fox, 2013), Greek philosophy (Brown, 2013)
and the Common Law legal code (Brundage, 2000). All of these derive from the basis
of male supremacy and have led to patriarchal societies.
There is a long heritage of Domestic Violence being seen as a ‘private affair.’ 19th
Century courts document numerous cases of pregnant women being beaten even when
in labour (Wojtczak, 2009). The Victorian attitude was one of resignation, there
appeared little a woman could do to stop violent attacks and only the prosecution of a
man for extreme violence was acknowledged. Law enforcement at the time also dealt
with Domestic Violence in a dismissive and derogatory way (Curran, 2010). It was not
seen to be in the ‘public interest’ and the police did not wish to intervene (Truninger,
1971). Such attitudes contributed to and mitigated the violence by ‘playing down’ its
significance.
‘It’s just a domestic’ Curran (2010)
Society would still prefer to think of Domestic Violence as an issue that affects only the
lower, uneducated classes (Aaltonen, Kivivuori, Martikainen & Salmi, 2012). However,
in the 21st Century it is well documented that Domestic Violence knows no boundaries
of class, colour, or religious persuasion (Khalifeh, Hargreaves, Howard & Birdthistle,
2013). Pizzey, an early social campaigner of the 1970’s argued that there is ‘indifference,
red tape, callousness and simple incompetence’ between those that needed help and the
agencies that might provide such help. This was seen as detrimental to both women and
children (Pizzey, 1974, p91). It has taken decades of campaigning and government
lobbying to highlight the damaging effects DV has on women, children and family life
(Harvie & Manzi, 2011 & Weldon & Htun, 2013). The Domestic Violence, Crime and
Victims Act 2004 created the biggest overhaul of the law on domestic violence in the last
30 years. The Act made significant changes to the way in which instances of domestic
violence are dealt with by the courts, together with other measures such as multi-agency
risk assessment committees (MARAC) which were created to improve the treatment of
victims and witnesses of domestic crime. In an effort for agencies to work and learn
together, multi-agency domestic homicide reviews have been established to analyse
deaths which are a result from violence by a relative, or within an intimate personal
relationship.
9
10. In addition to changes in the Law, and in determination to address this sensitive issue at
an early stage, the Royal College of Midwives have issued practice guidelines to their
staff, as statistics show that Midwives are uncovering DV at much lower rates than
estimates in the literature (Mezy Bacchus Haworth & Bewley, 2003). Lazenbatt
Thompson-Cree & McMurray (2005) reported that Midwives were reluctant to enquire
about DV as doing so created tensions between their clinical role and what could be
perceived as surveillance. Whilst professional awareness has increased over the years, it
appears that the same barriers exist which prevent Midwives from asking (Lazenbatt
Thompson-Cree & McMurray 2005, Mezy Bacchus Haworth & Bewley, 2003), even
when these factors are mitigated for, such as a training programme to enhance
confidence levels or the time to attend (Aldridge, 2013).
This study aims to explore if such attitudes are consistent with previous findings.
Depth of Understanding
As Domestic Violence has shifted from being ‘unknown’ to ‘known’ (Stanley, Miller,
Richardson Foster, and Thomson, 2010) the scale of DV incidents appears
overwhelming with thousands reported annually in Buckinghamshire alone. Due to the
volume, agencies (Police and Social Care) have to ‘triage’ the reports to be able to deal
with them. The risk of this is that many ‘minor’ incidents are not actioned which has the
potential effect of minimising or even normalising it. Perhaps Midwives believe that they
alone are expected to tease out the elements of risk, dangerousness and resilience of a
woman (Peckover, 2013) to provide protection for the mother and unborn child.
However, referral rates from Midwives to multi-agency risk assessment committees
(MARACs) are very low. On completion of the Domestic Abuse Stalking and
Harassment form (DASH), all women that have been risk assessed as ‘high’ are
discussed (Richards, Letchford and Stratton, 2008). However, there is a shortage of
Midwives nationally and case-loads are high (Price, 2012). The MARAC process can
also take time and perhaps the enormity of the task and of their case-loads prevents
Midwives from enquiring about DV in the first place. As identification of Domestic
Abuse increases, it raises the question as to whether the categorisation of ‘it’s just a
domestic’ will once again be the default position for busy professionals operating in
overstretched services (Peckover, 2013). This issue will be investigated in this study.
10
11. Conflicted Emotions
The prevalence of domestic violence means it is likely that Midwives will encounter
women who have experienced abuse at some stage in the course of their work and need
to be adequately prepared. 15 years ago, Scobie & McGuire (1999), recognised the
impact of DV on pregnant women and highlighted the Midwives’ lack of confidence
when enquiring about DV. Midwives felt ill prepared due to lack of training and feared
that they did not know how to support a woman if she did disclose abuse within a
relationship. In addition, they were unclear of how and when they would broach the
subject, especially when women attended appointments with partners or other family
members. Changes in attitudes amongst Midwives can be perceived as moving slowly.
According to Goldblatt (2009), working with abused women can have detrimental
emotional cognitive and behavioural influences on practitioners such as transference of
high anxiety (Neumann, & Strack, 2000) and low emotion resulting in vicarious
traumatisation. The resulting effect was to not look or screen for Domestic Abuse; for
whilst Practitioners felt empathy and compassion, they also felt anger and confusion.
The analysis of the data in this study will be mindful of this issue.
Child Protection
Although pregnancy is no protection from violence, (Zanville, & Cattaneo, 2012) many
pregnant women stay with their partners as a means of preventing the escalation of
violence caused by attempting to leave (Enander, 2010). Yet, it would be expected that
both the Midwife and Mother see the protection of the unborn as a priority that could
be the catalyst for change. Engnes, Lidén & Lundgren (2012) described the women in
their study as needing help in order to make the changes, yet they felt embarrassed and
ashamed to find themselves in such situations. The same feelings were expressed by
Midwives in early studies when discussing DV (Johnson, Haider, Ellis, Hay, & Lindow
2003) and (Mezey, Bacchus Haworth & Bewley 2003). However Engnes, Lidén &
Lundgren (2012) suggested that professionals had to overcome such feelings in order to
prioritise the unborn infants’ safety, whilst preserving the mother/Midwife relationship.
For those women who have experienced intense levels of coercive control from partners
(Williamson 2010), speaking about DV takes courage as many have few supportive
networks to rely on and struggle to control the situation (Edin, Dahlgren, Lalos &
Högberg, 2010). They may see the Midwife as their only means of advocacy, whilst at
11
12. the same time fearing that the consequences of disclosure will result in referrals to Child
Protection agencies.
The lived experience for many women experiencing Domestic Abuse is fear. This can
be seen from at least three perspectives: fear of what a partner may do if the disclosure
becomes known to them, fear from ‘authority’ figures and the fear of being seen as an
‘unfit’ Mother and even having the baby removed from their care following delivery
(Crittenden, Farnfield, Landini, & Grey, 2013). Domestic abuse also has strong
associations with child abuse which can affect the infants’ physical and emotional health,
their learning and their capacity to form positive relationships throughout their lives
(Lazenbatt, 2012). Flaherty, Sege, & Hurley, (2009) suggested infant maltreatment is one
of the most serious events undermining healthy psychological well-being and
development. No other social risk factor has a stronger association with developmental
psychopathology. Given the serious consequences of this social phenomena, it is
surprising that the research viewed (Lazenbatt, Thompson-Cree, & McMurray, 2005
Crawford, Liebling-Kalifani, & Hill, 2013) suggested a reluctance by Midwives to ask
about DV. The rationale for this study is to examine why this might be the case.
The Centre for Maternal and Child Death Enquiries
In modern society, pregnant women are encouraged to speak to their unborn from the
moment of conception; getting to ‘know’ and ‘connect’ with them is part of the
transition into motherhood (Levendosky, 2013) and is seen as the foundation of a
strong and secure attachment (Levendosky, Lannert & Yalch, 2012). Bowlby (1980)
recognised that the explanation for much human behaviour has its basis in the mother-
infant interaction. Specifically, more avoidant or anxious individuals are less likely to
express affection and deal with conflicts (Gay, Harding, Jackson, Burns & Baker, 2013).
Dutton & White (2012) further suggested that any set of psychological factors that have
anxiety or fear as a component affect the status quo of the relationship, leading to an
inability to resolve areas of conflict without resorting to verbal or physical aggression. It
would seem counter-intuitive to stay with a violent partner, thus exposing the baby to
harm (Bell, & Naugle, 2006). Further, Theobald & Farrington (2012) suggested the long
term impact of this ‘highly charged’ environment for the baby impacts hugely on an
individual’s emotional and developmental trajectory for later life transitions. This would
seem especially poignant in light of the fact that the Domestic Violence definition has
been extended by the Home Office to include girls from 16 years old, who under the
12
13. definition of the Children Act 1989 are still ‘children’ themselves. Motz reports that a
basic understanding of attachment models and disturbed attachment styles can be
helpful; as abetter understanding could help to inform about the relationship difficulties
some women face (Motz,2010, p342). The Centre for Maternal and Child Enquiries
(2011) (CMACE) highlighted that during 2006-2008, Domestic Violence featured in the
deaths of 34 women, for 11 of those women the abuse was fatal and the direct cause of
death. An intervention by a Midwife may ‘break the cycle’ of intergenerational abusive
and damaging relationships (Lapierre, 2010). This study focuses on the perceived
attitudes of Midwives and may highlight any attitudinal changes from previous studies.
Intuition
In real life situations, problems present themselves in ways that may or may not be
‘picked up’ by Midwives, or indeed any Healthcare Professional. Husso, Virkki, Notko,
Holma, Laitila & Mäntysaari (2012) described problem situations as ones that are
puzzling, worrying or something you cannot ‘put your finger on’. In nursing, the use of
intuition was hotly contested (Lyneham, Parkinson, & Denholm, 2008) and was not
seen as the basis for sound clinical decision making. However, to dismiss intuition as
invalid is to underestimate the fact that intuition is based on a combination of
experience and knowledge through explicit learning and clinical practice (Witteman,
Spaanjaars, & Aarts, 2012). Whilst Midwives may have an ‘inkling’ about something,
reluctance to intervene may result from a fear of ‘getting it wrong’. In addition, fear of
offending has previously been cited as a reason for not asking the question. Ethical
decision making is complex. Although guided by the Nursing and Midwifery Council
(2002), Varcoe, Doane, Pauly, Storch, Mahoney, McPherson, Brown, Starzomski
(2004) suggested nurses working with their own values could have competing interests
with their organisations. Any action or inaction seen in the clients’ ‘best interests’ has to
be carefully considered (Walker, Kershaw & Moon, 2009), as the stark reality is that two
women are killed each week at the hands of their partners or ex partners (Richards,
Letchford, and Stratton 2008). For pregnant women an early intervention from a
Midwife may prevent such a tragedy.
13
14. Psychological Paralyses
Taylor, et al (2013) expressed surprise to find that some health professionals believed
the women themselves played a part in or contributed to the DV. Perhaps this should
not come as a surprise. Health Professionals such as Midwives and Nurses are
predominately female and domestic violence is predominantly gender based (Anderson,
2013). Women have often found themselves blamed for staying in violent relationships,
especially where children are involved (Enander, 2010). Society places women at the
‘heart’ of the home and central to its overall function (Nicholas, 2013). Leaving the
home takes considerable courage and comes with a high personal and emotional cost.
Victims may be said to have a ‘psychological paralysis’ (Hayes, & Jeffries, 2013) which
prevents them from action, increasing a sense of ‘the futility of it all’. Such psychological
paralysis may also be reflected in the beliefs of the Midwives in that the ‘emotion’ of
dealing with DV increases their sense of the futility of intervening, especially if they
believe that the women will go back to their abusive partners. Perhaps then
organisations are not paying enough attention to the affect that working with Domestic
Violence has on practitioners. Expecting staff to effectively differentiate between their
home and professional lives is unrealistic without putting something more than ‘training’
in place. While many practitioners may not recognise ‘burnout’ in themselves, Coetzee,
& Klopper (2010) recognised it as a state of mind that progresses from a state of:
compassion discomfort, to compassion stress and finally to compassion fatigue; which if
not effaced in its early stages can permanently alter the compassionate ability of the
nurse. This presents a significant challenge to organisations, as the psychological
wellbeing of staff is seen as critical for an effective work force (Haslam, Jetten, Postmes
& Haslam, 2009). The question of adequate support will be addressed within the study.
Domestic Violence in Perspective
14
15. However front-line practitioners perceive Domestic Violence this issue is firmly on the
Maternity strategic agenda as the safety of not one but two individuals are placed at risk
(Price, Baird, & Salmon 2007). To offer a perspective, in Obstetric care worldwide the
prevalence of pre-eclampsia ranges from 3 to 8% of all pregnancies (Anderson, Olsson,
Kristensen, Akerstr¨om & Hansson 2012). Whereas, the findings of the Multi-Country
Study on Women's Health and Domestic Violence against Women show average
prevalence rates between 30% and 60% (García-Moreno, Jansen, Ellsberg, Heise, &
Watts, 2005). It would be considered clinically negligent to ignore or discharge a
pregnant woman with pre-eclampsia, yet women experiencing Domestic Violence can
find themselves in this position. Griffiths (2102) informs that civil law allows women,
usually in the form of compensation, to seek redress if they believe that harm has been
caused through a Midwife's clinical carelessness. However, there is no evidence to
suggest that this course of action is applied when discharging a woman back to a violent
situation.
There appears to be support and guidance from the government (DoH, 2005) and an
expectation from the local NHS Trusts that Midwives will ask this question. However,
the fact remains that this is not an easy task and Midwives as well as many other health
professionals, face real challenges in responding safely and effectively to the increased
pressure to identify women in abusive relationships (Lazenbatt, Thompson-Cree, &
McMurray, 2005).
Purpose and Rationale for this study
In the UK, Domestic Abuse has shifted from ‘behind closed doors’ into the public
arena. It is now firmly established as an important public issue and this is reflected in
national maternity policy (Peckover, 2013). Midwives are often the first healthcare
professional a woman will disclose to about Domestic Abuse, if asked. The relevance
and significance of Midwives routinely asking about DV, is linked directly to the adverse
and even fatal foetal and maternal outcomes of violence perpetrated against the
expectant mother. Intervening could provide an opportunity to prevent such adverse
outcomes, yet Midwives demonstrate reluctance in initiating such questions routinely.
Understanding such reluctance is crucial if the long term patterns of abuse are to be
reduced. I was previously involved in the Homicide review of a young local mother of
two very small children and I believe that hindsight can usually provide us with some
learning. I was struck by the findings as for me this case highlighted the lack of
15
16. information sharing between Health Practitioners. In addition, the mother was not
asked RCE directly by any health practitioner during her two very recent pregnancies.
This was seen as a lost opportunity, (Storer, Lindhorst, & Starr, 2013).
Aims of this study
The findings from the Homicide Review prompted the rationale for this study which
sought to gain an understanding of the Midwives’ attitude to asking about DV. This
study differs from other studies in that it is not looking at the effect of training to
increase the regularity or consistency in which questions are asked. The study aims to
draw on the experience of asking about DV in real life situations and to explore any
subsequent effects.
Methodology
Design & Materials
Based on the literature previously discussed and my personal experience of participating
in a Homicide Review, for this qualitative study I designed a semi-structured
questionnaire to facilitate and investigate the research question. A poster (appendix 1)
was prepared and widely circulated within all maternity settings, covering both Hospital
and Community bases approximately 8 weeks before the study began. The poster
outlined the aims of the study and the confidential nature of the interviews conducted. A
Dictaphone was used for recording purposes and the subsequent recordings were stored
securely on a private PC.
Participants
Broad participation was encouraged by opening the study to all Midwives across the
whole Trust. This included: ward, clinic and community settings. The final sample
consisted of five Hospital and five Community Midwives, therefore 10 individual semi-
structured interviews were conducted. The participants were all qualified registered
Midwives with a range of experiences and qualifications from 3 years to 31 years post
qualification. Two Midwives were part-time and five were full time. Three did not
comment. One participant divided her time between the Community and the Hospital,
but at the time of interview she was working in the Hospital and was coded as a Hospital
Midwife. All the Midwives were female as there are no male Midwives currently working
within this Trust.
16
17. Procedure
I conducted ‘drop in’ sessions in both Hospital and Community settings. At first, the
Midwives were recruited randomly if they were available and willing to complete the
interview at the time. However, the take up was poor and conducting the research this
way resulted in several failed attempts to meet with interested Midwives; particularly
Hospital based Midwives who are dependent on shift patterns and do not have the same
time flexibility as Community Midwives. I wanted to include Midwives from all areas of
practice in order to gain as much information as possible from as wide an audience as
possible. To enable participation, I made myself available at the beginning and end of
shifts at handover time; this took several attempts but did increase the chances of a
Hospital based Midwife being available and willing to interview. The interview, using the
semi-structured questionnaire, took place on Trust property during normal working
hours. Each Midwife was seen in a private room within the maternity building. The
purpose of the research and the consent form were explained and both the participating
Midwife and I signed the informed consent form (appendix 2). The question of
anonymity was discussed and participants were assured that the information would be
safely and securely stored. Participant identification would not be disclosed to anyone
other than the researcher and the University supervisor. The participants were advised
that they could withdraw from the study up to 2 weeks following the interview; although
none of them did. The interviews were 20-35 minutes long and each was audio
recorded using a small Dictaphone. Each audio tape was transcribed by an assistant and
stored securely on a private PC. As this research is based on a sensitive subject, which
has become more prevalent, (appendix 3 debrief). I sought the advice of a senior
Midwife and occupational health adviser should any of the Midwives have required it.
However, none expressed the desire to discuss any issues following
completion of the interview. In fact, given the opportunity to talk about it, some
Midwives expressed great interest in the topic and found it ‘thought provoking’. A vast,
rich and colourful account of Midwives perceptions and attitudes was given freely by all
the Midwives. After each interview, a verbatim account was then transcribed by an
assistant. The transcriptions were then checked for accuracy against the original
recordings which I listened to numerous times. The semi-structured interview was
chosen to allow the participants a level of freedom to respond to the subject topic. The
opening question being ‘How useful do you feel it is to ask women about Domestic
17
18. Violence?’ I coded the responses to identify any strong features of the interviews. With
this, I endeavoured to ensure that as many codes as possible were identified that were
representative of the Midwives experiences and not based on any presumptions I may
have had prior to the study. I am aware that having additional coders may enhance the
‘trustworthiness’ of the data (White, Oelke, & Friesen, 2012).
Ethics
The Department of Psychology’s ethics committee approved this research as
consistent with the British Psychological Society’s Code of Conduct. The confidentiality
and anonymity of the participants were of paramount importance. The data collected
included names, whether they were a Community Midwife (CMW) or a Hospital
Midwife (HMW). Each Midwife was assigned a letter (ABCDEFGHIJ) for anonymity.
Data Analysis
The data was analysed following the six phases outlined by Braun, & Clarke (2008).
Thematic analysis offers a number of advantages, including clear identification of
prominent themes, organisation, structure and flexibility (Dixon-Woods, Sutton &
Shaw, 2007).The initial phrase involved repeatedly reviewing and listening to the audio
interview transcripts. I made headings from what I considered salient points although
many recurring comments overlapped. In an attempt to summarise, the main points
were placed under a single heading. From the initial 28 codes (appendix 4) several
overlapped, i.e. audit/paperwork/documentation. Each interview transcript was cross
checked in an effort to develop the themes that appeared most commonly (appendix 5).
Four main themes emerged but again, there was some overlap. Finally, like the original
research question, three themes emerged. These final three themes were considered to
be of overarching importance to the Midwives, informing their sense of duty and
responsibility for the pregnant women.
Results and Discussion
The three themes presented from the data are:
18
19. Environment
Consequences and
Experience
The themes will be discussed in turn with reference to other studies and with regard to
the possible implications for practice and possible further research.
Environment:
It appears that the environment in which the question about DV is raised is important to
the Midwives interviewed. Differences were observed between the frequency in which
Hospital Midwives and Community Midwives described their difficulty with asking
questions based in various settings. In clinic settings, some Midwives have very limited
contact with pregnant women. These Midwives may have a different perception towards
the importance or relevance of asking women questions about
Domestic Abuse; particularly when other more clinical/medical matters are competing
for their immediate attention. This held true even when the clinic in question dealt
mainly with high risk pregnancies.
‘Our managers tell us we have to ask this question. I physically cannot do it. When it is
a particularly quite clinic, there are more opportunities to do it but on a normal clinic, I
just don’t get around to asking the question,’ HMW2/B
‘We are aware of its importance because of the media and of course pregnancy
exacerbates this situation. It is a very awkward question to ask a stranger. The
community Midwife may also be in this situation; however they are often not in such a
clinical environment and have a more general line of enquiry within the booking
history,’ HMW 2/B
Both Hospital and Community Midwives report that Community Midwives have more
of an opportunity at the booking appointment to ask any number of questions, both
medical and social. Certainly, all five Community Midwives expressed that they were not
afraid to be frank. ‘ I have always approached it the same way, relaxed, calm, routine, so
they don’t feel they are being targeted’ HMW1/A
One Midwife was very matter of fact: 'I ask the question as if I was asking to take their
temperature. Using the same tone of voice..............when you ask some of the girls
whether they have ever taken drugs they casually answer Cannabis, Es (Ecstasy)
Cocaine. They are quite honest about it, we never used to hear anything about that but
then we never asked' HMW1/A
19
20. Another: ‘I really try to do a booking at home, the women feel more comfortable and
are more likely to answer your questions in their own safe environment.’ CMW2/G
Two Hospital Midwives reported feeling unwilling to ask someone they hardly know
such a question, particularly if they are coming into the ward in labour as this could be
seen as inappropriate. Perhaps this is not surprising; it would be difficult to imagine that
either the Midwife or the labouring woman would see this as a priority over the safety of
the Mother and baby. However, one Hospital Midwife did believe that there was more
of an opportunity when the woman was in Hospital because the men ‘have to go home
at some stage’ HMW1/A. Community Midwives reported asking in broad terms and
did not report having had negative response from women, although one Midwife
reported that one lady recently said to her: ‘Well, what you do if I said yes?’ The
Midwife went on the explain what she could offer and signpost the Mother to other
agencies that could offer more practical help, the women denied experiencing domestic
abuse but she let the Midwife talk on. This informs us of the need to have current up to
date local information readily available. There was a sense that Hospital-based Midwives
were in at the 'sharp end'. The difficulties of dealing with the stressful event of labour
and an argumentative couple were expressed by one Midwife, who recalled a situation,'
‘on the delivery suit, because they were arguing, talking to her like she was deaf…we
could all hear him……he was stressing everyone……..I told him I’d call security if he
didn’t calm………….he did……….it’s her I feel sorry for, who needs that when you’re in
labour?’ HMW4/D
This excerpt graphically illustrating the difficulties Midwives and women face when an
already potentially stressful situation gets out of control. The Midwife clearly expresses
sympathy for the labouring woman and irritation with the partner.
An experienced midwife lamenting on the change in working practice as not so many
home visits are now carried out. The quote demonstrates a number of changes, both
from the general public and midwifery profession. ‘Oh yes. I don’t think we even
thought about the questions then, it was never mentioned in our training or practice. I
don’t think I was overly aware of the women’s situations. I worked on the labour ward
and so only got a small snapshot of their situation. I think then, the public were better
behaved in that situation. There wouldn’t be so many clues about their situation if you
hadn’t visited their home. Back then, we did a lot more home visits and so the patient
was more comfortable about the idea of you visiting their home, it was very
accepted’HMW3/C
20
21. Consequences
This theme explores the consequences for both the women and of the Midwife asking
the question. ‘At the moment there seems to be a number of women I have referred or
would like to refer but social services have done an assessment and don’t think they
need to be seen.’ HMW3/C Midwives play a pivotal role in the care of pregnant women
and may be one of the first Healthcare Practitioners that a woman will disclose to about
DV, if asked. The Midwives are in a unique position as people who can help and
influence a woman to disclose information, if they perceive the external support to be
effective. The consequences of violence to the pregnant mother are serious and can be
fatal. An intervention by means of signposting to other agencies may ‘break the cycle’ of
the abusive relationship. As one midwife relayed: I don’t’ know. Would she have told
me if I hadn’t asked, probably not’ CMW1/F This study confirmed the Midwives
awareness of the physical safety of the Mother and unborn child and is in line with other
studies. Nine Midwives expressed concern of the risks of DV for the baby and one
midwife highlighted the risk of maternal homicide. In line with other studies (Taylor et
al, 2013) (Lazenbatt Thompson-Cree & McMurray, 2005), the midwives expressed
incomprehension as to why some women appear to make the ‘choice’ to stay with
abusive partners. This could be indicative of midwives having only a basic or superficial
understanding of DV, as some believed the women themselves contributed to the DV.
Attribution is something we all do every day, usually without any awareness of the
underlying processes and biases that lead to our inferences (Storer, Lindhorst, & Starr,
2013). Old attitudes to DV are still influential and perhaps Midwives – like everyone
else - attribute blame, because they believe the victim should somehow be able to
predict, or at least prevent abuse by simply walking away. Women find themselves
blamed for staying in violent relationships, especially where children are involved
(Enander, 2010). Particularly when Midwives believe they have tried to help the women
flee the situation only to find she has returned to her partner.
‘Another lady who already had 4 children and was expecting her 5th, which she didn’t
want because of Domestic Violence. I felt very sorry for her and we really tried to help
her (me and the Health Visitor) but again she stayed with him’ CMW4/I
‘I would speak to my manager here, more to talk to somebody, to clarify the situation
and see if I am on the right path. Then I would be inclined to have a chat with the
woman herself and say that I have concerns about her and if I felt that there was a
21
22. problem the concern would be for the unborn baby. The mother may have chosen to
remain in a certain situation; the baby doesn’t have this choice. CMW2/G
Pregnancy is no protection from violence so many women make complex choices
(Zanville, & Cattaneo, 2012). The reasons for staying or leaving a partner are multi-
faceted; sometimes they stay as a means of preventing the risk of escalation caused by
attempting to leave (Enander, 2010). This study demonstrated the emotional impact of
working with clients who may be classified as ‘high risk’ but who may not recognise
abuse in their relationship, or minimize the effects of it on themselves, their unborn or
their children. The consequences of DV are varied and women do not present with one
set of symptoms or injuries, such varied presentations can make it difficult to assess. For
Midwives, this may be a particularly important and difficult dichotomy in that they have
clinical responsibility for two lives.
‘It did impact on my thoughts, its all well and good asking the question …..but it’s what
happens in the end I suppose……………it was her home, money, stigma…..she said going
to a refuge left her and the children with nothing ….. for all of them,…………he was a
good father in many ways, ……….the drink affects him’ CMW4/I
One Midwife was clear what she thought of violent men:
‘Banish men who batter women’ CMW2/G
‘Yes, when I asked an Asian lady she disclosed to me at booking that her husband had
hit her once. When I asked her how she felt now, she felt that it wasn’t a problem and
that he knew that if it happened again he would be out CMW2/G. The Midwife said she
was impressed by her. The Midwives were aware of the consequences of managerial and
peer scrutiny of the Maternity records. Five Midwives described difficulty with
documentation. ‘On another point there is serious violence where babies are victims
themselves. We had a recent case of a baby taken to A&E with shaken baby syndrome
and then I don’t think we had the notes where we could actually document that we had
asked the question.’CMW4/I Although they reported being well supported by
managers, poor performance in documentation of RCE could be seen as a disciplinary
matter, as policy and procedure now indicate this has to be completed. Five Midwives
discussed writing this in the records. It would be disappointing if an organisation
threatened disciplinary action; more important is the role that supervision plays in
supporting the midwives emotionally with this type of work. Not one of the midwives
talked about supervision in a formal way, although they did talk about the support they
received from specialist Midwife for Child Protection/Managers and peer support.
22
23. Experience of asking
This theme arises from the complexities faced by both women and Midwives of asking
the question. It can be seen from a practical training perspective and from a personal
resilience perspective. Quite a lot of women will joke about it and make light of the
question CMW3/H Midwives have a vague ‘working’ knowledge of the potential
effectiveness of MARAC. Until DV & MARAC training becomes mandatory for health
practitioners, the safety and welfare of pregnant women remains at risk as practitioners
will fail to recognise abusive behaviour. For example, it is important to understand that
domestic violence stalkers (often ex-partners), are more likely to be violent than any
other type of stalker. Additionally if they make a threat, 1 in 2 of them will act on it
(McEwan, Mullen, McKenzie & Ogloff, 2009). Efforts to improve safety are seen as a
priority for the criminal justice system (CPS, 2013) and the Health Service must also
send a powerful message that violence against women and girls will not be tolerated.
Midwives were confident in their clinical role and expertise; they did not see themselves
taking on other roles as they were aware of their limitations and perhaps of others: ‘We
are trained Midwives, not Social Workers’ CMW3/H
‘Many of the roles, Health Visitor, School Nurse didn’t come in to their roles thinking
they would be so involved with safeguarding children’.HMW3/C ‘It makes me feel
quite responsible, that I need to do something to make sure they are safe. It is a lot
easier if they do want to leave and are willing to do something about it. You can have a
situation where they don’t want to do anything about it. I have got one at the moment
who went to the police because her partner tried to strangle her. She has subsequently
dropped the charges and is now denying it all, but obviously she disclosed it, then it's
difficult, you have to ask is she safe? Is the baby safe you think if they don't know what
do to how are we supposed too? CMW3/H
The experience of being exposed to potentially violent relationships was captured by
one CMW: 'You have to be non-judgemental. Often, we do get upset, one of our
midwives received some horrible texts from a patient, really abusive because she had
been the one to ask the question'. Asking the question may not always elicit the response
you were expecting. As one Midwife described, when asking the woman about DV she
explained that her own mother had been abusive to her. Midwives have to be prepared
to offer some level of emotional support in situations like this.
23
24. Particularly when as professionals, we should be aware of the long term consequences of
abusive relationships.
‘Yes, I have found from experience that I have probably had X women disclose and all
of those women have received help, even one who actually went to Child Protection and
her husband went to court and eventually she did have him back.’ CMW4/I
‘I did have one girl who was a victim and when I went to book her, he was at work and
she burst into tears and said he had started hitting her and she wanted to have an
abortion and tell him she had had a miscarriage. She did leave him in the end. She was
an English Asian girl living with his family. I gave her the information about abortion
because that is what she wanted. I have seen her since and she is fine.’ HMW1/A
Such excerpts are informative, as Midwives should be aware that these women's lives are
not just divided into two parts, the pre-leaving part and the post-leaving part. The
experience of living with DV stays with them. As Crawford, Liebling-Kalifani, & Hill,
(2013) suggest, they remain wary of reprisals from ex-partners, living with the fear that
'services' will intervene and concern at their ability to cope.
‘People have gone through things in their relationships… you can’t tell what they’ve been
through’ CMW2/B
One Midwife expressed shock at the experience of one 25 week pregnant women
describing to the Midwife her journey through an Accident and Emergency department.
The explanation of a fall down the stairs was immediately accepted as truthful and not
questioned. It was not until she was admitted to the labour ward, that the subject of DV
was approached and the expectant Mother said she had been pushed. This narrative
highlights that the clinical presentation in some areas (A&E) takes priority and ‘follow
on’ questions about how the injury happened are not always asked (Basu & Ratcliffe,
2013). Given the prevalence of DV, this is a curious finding, although it is recognised
that obtaining an accurate understanding of injury to DV victims is difficult, as there is
not a standardized method of describing or defining how injuries occur (Sheridan, &
Nash, 2007). That said, as victims of violent assault seeking help will usually attend an
A&E, staff should be able to recognise and advise patients on possible avenues of
support as well as treating their physical injuries.
This study supports the findings of Goldblatt (2009) by suggesting that the Midwives’
encounters with abused women illustrate a range of reactions. Not just about the
women’s stories, but also the role that other professionals may play in the overall care of
the pregnant woman.
24
25. ‘In A&E they didn’t ask……….. and she didn’t tell…………’ CMW Intuition plays a part in
this study also. There is evidence to suggest that using ‘intuition’ can change
outcomes for patients and certainly Midwives in this study expressed it well,
‘I think your instincts tell you to escalate things……even when she says it’s her
fault……..you can call the police if you feel it’s dangerous,’ HMW1/A
‘it was useful for her, she was truthful, she didn’t really understand it just felt he was
suffocating her lifestyle while being lovely and supportive…… we both knew what was
happening, but you can’t mind read and could get it wrong……but if you do where’s the
harm, if they are OK they’ll so say’. CMW5/J
‘I knew something wasn’t right, but I didn’t know why. She was 5 days post caesarean
section and he had even sent her to Asda to collect the photographs. She shouldn’t even
have been driving. He didn’t want to risk me being there with her when he was out. I
remember being quite uncomfortable about ‘it.’ HMW1/A
During the interviews Midwives demonstrated an acute awareness of Domestic Violence
and the implications for pregnant women. Bacchus, et al (2002) and Lazenbatt, et al
(2005) suggest that Health Professionals are too slow to respond to the growing evidence
that women welcome the opportunity to be asked about DV and that fear of offending
or embarrassment should not stand in the way.
‘I have always approached it in the same way, very relaxed, calm and routine, so they
don’t feel they are being targeted. One woman said “well sort of” and when I asked her
what she meant, she said “he pushed me around a bit”. I did explain to her that
research shows these things can escalate during pregnancy and advised her to keep an
eye on things. I gave her the numbers and said we could talk about it later. HMW1/A
Yet Midwives in this small sample expressed creative ways and means of asking the
question, aware of taking perhaps the only opportunity there was to ask. Six Midwives
spoke of ‘lying and making excuses’ to get the women alone as they were acutely aware
of need for confidentiality and safety. Attitudes have changed. This is in line with Baird,
Salmon & White (2013) who reported positive changes in attitude in the five years since
their original research to asking the question.
‘Yes, we are a lot more aware. There isn’t such a stigma and they are looked on as the
victims. We know they are psychologically down-trodden’. HMW1/A
‘If you can never get a chance to ask the woman properly and you can see that every
time you see her she is accompanied, you know there just was no opportunity to ask any
25
26. questions. Sometimes this kind of behaviour, along with other suspicions can give you a
clue that something is wrong. I don’t think it is harmful [to ask] in any way’.HMW3/C
However, this can take time as one midwife said reflecting on her experience whilst
working in the Community; ‘it took me 8 months to get the women on her own…….I
did eventually during a home visit when he was at work………in her case it was OK, but I
felt better for asking’. HMW1/A
For this Midwife, having an unanswered question about Domestic Violence was like
‘unfinished business’. The Midwife did not feel her work was complete until this task
had been done. This demonstrates the impact of DV on professionals and this evidence
should not be over looked or minimized. Six of the Midwives expressed the importance
of support from senior managers and felt they were supported by their immediate
colleagues and line managers.
Overall Summary & Conclusion
This study sought to explore the ‘lived’ experiences, perceptions and attitudes of
Midwives to asking pregnant women about Domestic Violence. NHS Trust initiatives
and Government responses to Domestic Abuse have placed this firmly on the Maternity
agenda and Midwives are now expected to routinely ask women about it. However, this
small scale study suggests some ambiguity towards asking the question. Midwives have a
clinical responsibility for the safe delivery of mother and baby. Therefore, dealing with
DV extends this clinical responsibility and requires the Midwife to put aside any
‘personal’ thoughts and feelings about asking aside. Whilst they did not wish to be
judgemental, many of the Midwives had the experience of supporting the women only
to find they had returned to the relationship. The sense of futility involved in intervening
may impact on levels of empathy and compassion. The data demonstrated the
seriousness in which Midwives saw their role coupled with the ‘raw’ sense of the
complex and difficult world experienced by some of the women they worked with. That
said, Midwives would also benefit from mandatory training as they appeared to lack a
real understanding of the role that MARACs played in assessing and managing risk for
women, or the role they could play by referring such vulnerable women. Being actively
involved in a multi-agency approach to supporting the victim may in turn increase a
sense, for the midwife, that everything that can be done is being done. Such narratives
provide important and sometimes overlooked information about the personal effect on
the Midwives in relation to their professional lives. The trust as an organisation faces
26
27. real challenges if it is to support staff, particularly psychologically, with the impact of
working in difficult and emotionally demanding situations. This only serves to highlight
the importance of formal reflective clinical supervision that can inform clinical practice
and contain practitioners. The study also highlighted some environmental differences to
asking the question and was dependent on the clinical area the Midwives were working
in. This was an unexpected variance, where clinical priorities outweighed social ones.
Perhaps this should not be so surprising when the clinical safe delivery of mother and
baby must take priority. The issue of asking the question in variable settings may benefit
from further research as there was a sense that hospital Midwives felt ‘pressurised’ to ask
and worried about possible disciplinary action if they failed to do so.
This study addressed the initial aims of the research question; however it appears that
‘asking the question’ is a complex and difficult responsibility, with many factors
influencing Midwives in their decision to complete this task. Midwives are aware of their
unique position in identifying DV and need regular on-going training and reflective
supervision in order to achieve the goals set both nationally and locally.
27
28. References
Aaltonen, M., Kivivuori, J., Martikainen, P., & Salmi, V. (2012). Socio-Economic Status
and Criminality as Predictors of Male Violence Does Victim’s Gender or Place of
Occurrence Matter?. British Journal of Criminology, 52(6), 1192-1211.
Anderson, U.D., Olsson, M.G., Kristensen, K.H., Akerstr¨om, B & Hansson S.R.,
(2012) “Review: biochemical markers to predict pre-eclampsia,” Placenta, vol. 33, pp.
S42–S47.
Anderson, K. L. (2013). Why Do We Fail to Ask “Why” About Gender and Intimate
Partner Violence?. Journal of Marriage and family, 75(2), 314-318.
Aldridge, J. (2013). Identifying the Barriers to Women's Agency in Domestic Violence:
The Tensions between Women's Personal Experiences and Systemic Responses. Social
Inclusion, 1(1), 3-12.
Bacchus L., Mezey G. & Bewley S. (2002) Women's perceptions and experiences of
routine enquiry for Domestic Violence in a maternity service. International Journal of
Obstetrics and Gynaecology 109, 9–16.
Bacchus, L., Mezey, G., Bewley, S., &Haworth, A. (2004).Prevalence of Domestic
Violence when Midwives routinely enquire in pregnancy. BJOG: An International
Journal of Obstetrics & Gynaecology, 111(5), 441-445.
Baird, K., Salmon, D., & White, P. (2013).A five year follow-up study of the Bristol
pregnancy Domestic Violence programme to promote routine enquiry. Midwifery.
Bailey, J., & Giese, L. (2013). Marital cruelty: reconsidering lay attitudes in England, c.
1580 to 1850. The History of the Family, (ahead-of-print), 1-17.
Basu, S., & Ratcliffe, G. (2013).Developing a multidisciplinary approach within the ED
towards domestic violence presentations. Emergency Medicine Journal.
28
29. Bell, K. M., & Naugle, A. E. (2006). Understanding stay/leave decisions in violent
relationships: A behaviour analytic approach. Behaviour and Social Issues, 14(1), 21-45.
Bostock, J. A. N., Plumpton, M., & Pratt, R. (2009). Domestic Violence against women:
understanding social processes and women's experiences. Journal of Community &
Applied Social Psychology, 19(2), 95-110.
Braun, V. & Clarke, V. (2008) Qualitative Research in Psychology. Using thematic
analysis in psychology. Qualitative Research in Psychology, 3:2, 77-101
Brundage, J. (2000). Domestic Violence in Classical Canon Law. In R. W. Kaeuper
(Ed.), Violence in Medieval Society (pp. 107–128). Boydell: Woodbridge, Suffolk.
Brown, K. (2013). Antigone Revisited: Greek Mythology Through an Attachment
Lens. Attachment: New Directions in Psychotherapy and Relational Psychoanalysis,
7(1), 64-83.
Bowlby, J. (1980). Attachment and loss: Vol. 3. Sadness and depression. New York:
Basic Books.
CAADA (2012) Resources for People Involved in MARACs, available online at
http://www.caada.org.uk/marac/Resources_for_people_involved_in_MARACs.
Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing
maternal deaths to make motherhood safer: 2006–08. The Eighth Report on
Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG
2011;118(Suppl. 1):1–203.
Chaplin, R., Flatley, J. and Smith, K. (Eds) (2011) Crime in England and Wales
2010/11: Findings from the British Crime Survey and Police Recorded Crime, London,
Home Office.
Coetzee, S. K., & Klopper, H. C. (2010). Compassion fatigue within nursing practice: A
concept analysis. Nursing & Health Sciences, 12(2), 235-243.
29
30. Crittenden, P. M., Farnfield, S., Landini, A., & Grey, B. (2013). Assessing Attachment
for Family Court Decision-Making. Journal of Forensic Practice,15(4), 2-2.
Crawford, E., Liebling-Kalifani, H., & Hill, V. (2013).Women’s understanding of the
effects of domestic abuse: The impact on their identity, sense of self and resilience. A
grounded theory approach. Journal of International Women's Studies, 11(2), 63-82.
Crown Prosecution Service (2013)
http://www.cps.gov.uk/publications/prosecution/domestic/domv.html#a01
Curran, L. A. (2010). No Further Action? A critical examination of the past and present
police response to Domestic Violence. Internet Journal of Criminology 2010
Devries, K., Watts, C., Yoshihama, M., Kiss, L., Schraiber, L. B., Deyessa, N..& Garcia-
Moreno, C. (2011). Violence against women is strongly associated with suicide attempts:
evidence from the WHO multi-country study on women’s health and Domestic
Violence against women. Social science & medicine,73(1), 79-86.
Dixon-Woods M., Sutton A., Shaw R., et al. (2007) Appraising qualitative research for
inclusion in systematic reviews: a quantitative and qualitative comparison of three
methods. Journal of Health Services Research and Policy 12 (1), 42–47.
Duley, L., Meher, S., & Abalos, E. (2006). Management of pre-eclampsia. BMJ: British
Medical Journal, 332(7539), 463.
Dutton, D., & White, K. (2013).Male Victims of Domestic Violence. Retrieved
February, 9, 2013.
Dutton, D. G., & White, K. R. (2012). Attachment insecurity and intimate partner
violence. Aggression and Violent Behaviour.
Edin, K. E., Dahlgren, L., Lalos, A., & Högberg, U. (2010).“Keeping up a front”:
narratives about intimate partner violence, pregnancy, and antenatal care. Violence
against women, 16(2), 189- 206.
30
31. Engnes, K., Lidén, E., & Lundgren, I. (2012). Women’s experiences of important
others in a pregnancy dominated by intimate partner violence. Scandinavian Journal of
Caring Sciences.
Enander, V. (2010). “A Fool to Keep Staying”: Battered Women Labelling Themselves
Stupid as an Expression of Gendered Shame. Violence against women, 16(1), 5-31.
Feder G., Ramsay J., Dunne D. et al. (2009) How far does screening women for
domestic (partner) violence in different health-care settings meet criteria for a screening
programme? Systematic reviews of nine UK National Screening Committee criteria.
Health Technology Assessment 13, 1–1136.
Flaherty, E. G., Sege, R. D., & Hurley, T. P. (2009). Effect of early childhood adversity
on health, Archives of Paediatrics and Adolescent Medicine,, 160, 1232-1238.
Fox, V. C. (2013). Historical perspectives on violence against women. Journal of
International Women's Studies, 4(1), 15-34
García-Moreno, C., Jansen, H. A., Ellsberg, M., Heise, L., &Watts, C. (2005), WHO
multicountry study on women's health and Domestic Violence against women: initial
results on prevalence, health outcomes and women's responses. World Health
Organization.
Gay, L. E., Harding, H. G., Jackson, J. L., Burns, E. E., & Baker, B. D. (2013).
Attachment style and early maladaptive schemas as mediators of the relationship
between childhood emotional abuse and intimate partner violence. Journal of
Aggression, Maltreatment & Trauma, 22(4), 408-424.
Griffith, R. (2012). Accountability in Midwifery practice: answerable to mother and
baby. British Journal of Midwifery, 20(8), 601-602.
Goldblatt, H. (2009). Caring for abused women: impact on nurses’ professional and
personal life experiences. Journal of advanced nursing, 65(8), 1645-1654.
31
32. Harvie, P., & Manzi, T. (2011).Interpreting multi-agency partnerships: Ideology,
discourse and Domestic Violence. Social & Legal Studies, 20(1), 79-95.
Hamilton, L. H. A., Jaffe, P. G., & Campbell, M. (2013).Assessing Children’s Risk for
Homicide in the Context of Domestic Violence. Journal of Family Violence, 28(2).
Haslam, S. A., Jetten, J., Postmes, T., & Haslam, C. (2009). Social identity, health and
wellbeing: An emerging agenda for applied psychology. Applied Psychology, 58(1), 1-23.
Hayes, S. L., & Jeffries, S. (2013). Why do they keep going back? Exploring women's
discursive experiences of intimate partner abuse. International Journal of Criminology
and Sociology, 2, 57-71.
Henderson, A. (2001), Emotional labour and nursing: an under-appreciated aspect of
caring work. Nursing Inquiry, 8: 130–138.
Heise, L. L., Raikes, A., Watts, C. H., & Zwi, A. B. (1994). Violence against women: a
neglected public health issue in less developed countries. Social Science & Medicine,
39(9),1165- 1179.
Helmus, L., & Bourgon, G. (2011).Taking stock of 15 years of research on the Spousal
Assault Risk Assessment Guide (SARA): A critical review. International Journal of
Forensic Mental Health, 10(1), 64-75.
Home Office (2012) Cross Government Definition of Domestic Violence – A
Consultation Summary of Responses. Available at:
http://www.homeoffice.gov.uk/publications/aboutus/ consultations/definition-domestic-
violence/domestic-violence-definition
Husso, M., Virkki, T., Notko, M., Holma, J., Laitila, A., & Mäntysaari, M.
(2012).Making sense of Domestic Violence intervention in professional health care.
Health & social care in the Community, 20(4), 347-355.
32
33. Johnson, J. K., Haider, F., Ellis, K., Hay, D. M., & Lindow, S. W. (2003).The
prevalence of Domestic Violence in pregnant women. BJOG: An International Journal
of Obstetrics & Gynaecology, 110(3), 272-275.
Kavanaugh, V. M., & Miller, F. M. (2012).The Contribution of Violence to Pregnancy
Related Deaths in Virginia. Journal of Obstetric, Gynaecology, & Neonatal Nursing,
41(s1), S138- S139.
Kershaw, C., Nicholas, S. and Walker, A. (2008) Crime in England and Wales 2007/08.
Home Office Statistical Bulletin. London: Home Office. [online] Available at:
http://homeoffice.gov.uk/rds/pdfs08/hosb0708.pdf.
Khalifeh, H., Hargreaves, J., Howard, L. M., & Birdthistle, I. (2013). Intimate partner
violence and socio-economic deprivation in England: findings from a national cross-
sectional survey. American journal of public health, 103(3), 462-472.
Lapierre, S. (2010). More responsibilities, less control: Understanding the challenges
and difficulties involved in mothering in the context of Domestic Violence. British
Journal of Social Work, 40(5), 1434-1451.
Lazenbatt, A., Thompson-Cree, M. E. M., & McMurray, F. (2005). The use of
exploratory factor analysis in evaluating Midwives’ attitudes and stereotypical myths
related to the identification and management of Domestic Violence in practice.
Midwifery, 21(4), 322-334.
Lazenbatt A. & Thompson-Cree M.E.M. (2009) Recognizing the co-occurrence of
domestic and child abuse: a comparison of Community- and Hospital-based Midwives.
Health and Social Care in the Community 17, 358–370.
Lazenbatt, A. (2012). Recognizing the Co-Occurrence of Child and Domestic Abuse in
Pregnancy and the First Postnatal Year.
Levitt, H. M., & Ware, K. (2006). “Anything With Two Heads Is a Monster” Religious
33
34. Leaders' Perspectives on Marital Equality and Domestic Violence. Violence Against
Women, 12(12), 1169-1190.
Levendosky, A. A. (2013). Drawing Conclusions: An Intergenerational Transmission of
Violence Perspective. Psycho-dynamic psychiatry, 41(2), 351-360.
Levendosky, A. A., Lannert, B., & Yalch, M. (2012). The effects of intimate partner
violence on women and child survivors: An attachment perspective. Psycho dynamic
psychiatry, 40(3), 397- 433.
Lewis G. Centre for Maternal and Child Enquires (CMACE). Saving mothers' Lives:
reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report
on Confidential Enquires into Maternal Deaths in the United Kingdom. London:
BJOG 118: (Suppl. 1), 2011.
Lyneham, J., Parkinson, C., & Denholm, C. (2008).Explicating Benner’s concept of
expert practice: intuition in emergency nursing. Journal of advanced nursing,64(4), 380-
387.
McEwan, T E, Mullen, P E, MacKenzie, R & Ogloff, J R P (2009) ‘A study of the
predictors of violence in stalking situations’. Psychological Medicine 39: pp1469-1478
Mezey, G., Bacchus, L., Haworth, A., & Bewley, S. (2003). Midwives' perceptions and
experiences of routine enquiry for Domestic Violence. BJOG: An International Journal
of Obstetrics & Gynaecology, 110(8), 744-752.
Motz, A. (2008). The psychology of female violence: Crimes against the body. Taylor &
Francis.
Neumann, R., & Strack, F. (2000)." Mood contagion": the automatic transfer of mood
between persons. Journal of personality and social psychology,79(2), 211.
34
35. Nicholas, M. W. (2013). The Compulsion to Repeat Relationships With Abusive
Partners and How Group Therapy Can Help. International journal of group
psychotherapy, 63(3), 346-365.
Nittis, M., Hughes, R., Gray, C., & Ashton, M. (2013). Domestic violence
documentation project 2012. Journal of Forensic and Legal Medicine.
NMC, (2002) Nursing and Midwifery Council Code of Conduct for Nurses NMC,
London
Parkes, J. (2012). Masculinity and its Effects on Domestic Violence within the Working
Classes. leaving
Peckover, S. (2002) Domestic Abuse and women's health: the challenge for primary
care. Primary Health Care and Development, 3, 151-158.
Peckover, S. (2013). Domestic Abuse, Safeguarding Children and Public Health:
Towards an Analysis of Discursive Forms and Surveillant Techniques in Contemporary
UK Policy and Practice. British Journal of Social Work.
Pizzey, E. (1974). Scream quietly or the neighbours will hear (p. 116). A. Forbes (Ed.).
Harmondsworth: Penguin.
Price, S., Baird, K., & Salmon, D. (2009).Asking the question: antenatal Domestic
Violence. Midwifery: Best Practice, 5, 125.
Price, C. (2012). Stop the midwife shortage. British Journal of Midwifery, 20(9), 682-
682.
Ramsay, J., Richardson, J., Carter, Y. H., Davidson, L. L., & Feder, G. (2002). Should
health professionals screen women for Domestic Violence? Systematic review. Bmj,
325(7359), 314.
35
36. Ramsay, J., Rutterford, C., Gregory, A., Dunne, D., Eldridge, S., Sharp, D., & Feder, G.
(2012). Domestic Violence: knowledge, attitudes, and clinical practice of selected UK
primary healthcare clinicians. British Journal of General Practice,62(602), e647-e655.
Richards, L., Letchford, S. and Stratton, S. (2008) Policing Domestic Violence. Oxford.
Blackstone‘ s Practical Policing Oxford University Press.
Roberts S.J. (1983) Oppressed group behaviour: implications for nursing. Advances in
Nursing Science 5(4), 21-30.
Robinson, A. L., & Rowlands, J. (2009). Assessing and managing risk among different
victims of Domestic Abuse: Limits of a generic model of risk assessment& quest.
Security journal, 22(3), 190-204.
Salmon, D., Murphy, S., Baird, K., & Price, S. (2006). An evaluation of the effectiveness
of an educational programme promoting the introduction of routine antenatal enquiry
for Domestic Violence. Midwifery, 22(1), 6.
Scobie, J., & McGuire, M. (1999). The silent enemy: Domestic Violence in
pregnancy. British Journal of Midwifery, 7(4), 259-262.
Sheridan, D. J., & Nash, K. R. (2007). Acute injury patterns of intimate partner violence
victims. Trauma, Violence, & Abuse, 8(3), 281-289.
Skoda, H. (2009). Violent Discipline or Disciplining Violence?: Experience and
Reception of Domestic Violence in Late Thirteenth-and Early Fourteenth-Century Paris
and Picardy. Cultural and Social History, 6(1), 9-27.
Stanley, N., Miller, P., Richardson Foster, H. and Thomson, G. (2010) Children and
Families Experiencing Domestic Violence: Police and Children’s Social Services’
Responses, London, NSPCC and University of Central Lancashire.
Storer, H. L., Lindhorst, T., & Starr, K. (2013). The Domestic Violence Fatality
Review: Can It Mobilize Community-Level Change?. Homicide Studies.
36
37. Taylor, J., Bradbury-Jones, C., Kroll, T., & Duncan, F. (2013). Health professionals’
beliefs about Domestic Abuse and the issue of disclosure: a critical incident technique
study. Health & social care in the Community.
Theobald, D., & Farrington, D. P. (2012).Child and adolescent predictors of male
intimate partner violence. Journal of child psychology and psychiatry,53(12), 1242-1249.
Truninger, E. (1971). Marital violence: The legal solutions. Hastings LJ, 23, 259.
Usta, J., Antoun, J., Ambuel, B., & Khawaja, M. (2012).Involving the health care system
in domestic violence: what women want. The Annals of Family Medicine,10(3), 213-
220.
Varcoe, C Doane, G Pauly, B Storch, J Mahoney, K McPherson, G Brown, H
Starzomski R Ethical practice in nursing: working the in-betweens Journal of Advanced
Nursing, 45 (3) (2004), pp. 316–325
Viellas, E. F., da Gama, S. G. N., Carvalho, M. L. D., & Pinto, L. W. (2013). Factors
associated with physical aggression in pregnant women and adverse outcomes for the
newborn. Journal de pediatric, 89(1), 83-90.
Walker, A., Flatley, J., Kershaw, C., & Moon, D. (2009).Crime in England and Wales
2008/09. Volume 1: Findings from the British Crime Survey and police recorded crime.
London: Home Office.
Weldon, S. L., & Htun, M. (2013). Feminist mobilisation and progressive policy
change: why governments take action to combat violence against women. Gender &
Development, 21(2), 231-247.
White, D. E., Oelke, N. D., & Friesen, S. (2012). Management of a Large Qualitative
Data Set: Establishing Trustworthiness of the Data. International Journal of Qualitative
Methods, 11(3), 244-258.
37
38. Williston, C. J., & Lafreniere, K. D. (2013). “Holy Cow, Does That Ever Open Up a
Can of Worms”: Health Care Providers' Experiences of Inquiring About Intimate
Partner Violence. Health Care for Women International, (ahead-of-print).
Williamson, E. (2010). Living in the world of the domestic violence perpetrator:
negotiating the unreality of coercive control. Violence against women, 16(12), 1412-
1423.
Witteman, C. L., Spaanjaars, N. L., & Aarts, A. A. (2012). Clinical intuition in mental
health care: A discussion and focus groups. Counselling psychology quarterly, 25(1), 19-
29.
Wojtczak H., (2009) http://www.historyofwomen.org/
Zanville, H. A., & Cattaneo, L. B. (2012).The nature of risk and its relationship to
coping among survivors of intimate partner violence. Psychology of Violence,2(4), 355
38
