Description of the condition
Violence against women and girls is a major health and human rights concern (Beydoun 2010). Women can experience physical or mental abuse throughout their lifecycle, in infancy, childhood, adolescence, during adulthood or older age (Parker 1994; Petersen 1997). Violence has severe health consequences (Feder 2009), and is a social problem that warrants an immediate co-ordinated response from multiple sectors including healthcare providers and social workers (Goodwin 1990; Newberger 1992).
Violence against women by partners is referred to as domestic violence (DV), spousal assault, intimate partner violence (IPV), wife abuse, wife assault, and battered wife syndrome (Bohn 1996; McFarlane 1996). Most researchers define DV as threats of, or actual physical injury from hitting, slapping, punching, choking, kicking, injury with a weapon, or otherwise injuring an intimate partner (Browne 1997; Campbell 1992; Parker 2002; Stark 1999). Assault and coercive behaviours include physical, sexual, and psychological/emotional attacks, and threats against property, children and pets, economic coercion, and many more such acts. Some are injurious and criminal in nature, while others are not (Hedin 2000). The consequences of abuse are varied, and women suffering DV do not present with a particular set of symptoms. Given this variation, the concept of DV should not be conceptualised as a disease or syndrome, nor should it be considered as a specific health problem (e.g. injury or reproductive, physical, or mental health problem). In fact, more often than not, victims demonstrate strength and ability to take care of themselves and their infant in spite of often untenable situations. However, it is clear that abuse puts the victim at greatly increased risk of a multitude of physical and mental health problems (Howard 2010).
Although estimating the prevalence of DV is difficult (Ballard 1998) and estimates vary, especially during pregnancy, it is likely that most providers of women's healthcare services will encounter many pregnant women who are survivors of DV. For almost 30% of women who experience DV, the first incident occurs in pregnancy (Rodriguez 2001). The prevalence of physical abuse during pregnancy varies around the world: in Canada, reported prevalence ranges from 1.0% to 10.9% (Daoud 2012); in the United States, 0.9% to 20.1% (Gazmararian 1996 ); in the United Kingdom, 1.8% at booking, 5.8% at 34 weeks of gestation and 5.0% at 10 days postpartum (Bacchus 2004); in Sweden, 4.3% (Hedin 1999); in South Africa, 6.8% (Jewkes 2001); and Jejeebhoy 1998 has reported high rates of abuse in India. The prevalence of psychological and sexual maltreatment of women during pregnancy has also been reported at between 13% and 60% (Hedin 1999; Jahanfar 2007; Valladares 2005). DV is reported within all socio-economic class groupings, but it is most prevalent within the working and lower middle socio-economic classes (Babu 2009; Nagassar 2010).
Abuse during pregnancy is of particular concern because it is a threat to both maternal and child health (Lewis 2007; Lewis 2011; Shah 2010). It directly (e.g. via trauma to the abdomen) and indirectly affects the mortality and morbidity of fetus and mother. Other health-related problems and adverse economic circumstances enhance the risk of adverse pregnancy outcomes. It is a chronic problem for mothers and infants as violence exposure tends to continue after pregnancy (Taft 2009b).
Studies to date have demonstrated that physical abuse before, during, and after pregnancy is associated with reproductive health problems such as sexually transmitted diseases (Rodriguez 2001), urinary tract infection (Gazmararian 1996), depression, substance abuse (Rose 2010) and other mental health problems (Browne 1997; Canterino 1999; El 2005). Domestic violence is associated with a higher incidence of unwanted pregnancy (Browne 1997; Parker 2002) and intentional abortions (Canadian Centre for Justice Statistics 2000).
There are many negative effects of DV on pregnancy. The following harms have been clearly documented: maternal deaths (Lewis 2007; Lewis 2011; Saltzman 2003), low birthweight (Chamberlain 2000; Jewkes 2001; Lipsky 2003), placental abruption (Hedin 2000), preterm labour and delivery (Harwin 2006), fetomaternal haemorrhage, fetal death (Mezey 2000), intrauterine growth restriction (Janssen 2003), pregnancy complications due to trauma (Jejeebhoy 1998), miscarriage (Chamberlain 2000), maternal infections, and poor weight gain (Wiist 1999). In addition, DV negatively affects pregnant women's health behaviours (World Health Organization 2000) leading to delayed entry into prenatal care or to women seeking no care at all (Diaz-Olavarrieta 2002), and increases behavioural risks such as the use of tobacco, alcohol, and illicit drugs, and poor maternal nutrition (Bacchus 2004; Family Violence Prevention Fund 1999; Ng 2005; Parsons 2000; Wathen 2003).
Physical injuries to fetuses and infants, such as bruising, broken bones, and stab wounds, as well as death, have also been described (Ezechi 2004; Valladares 2005). Child abuse is also reported more often among families with a history of DV (Feldhaus 1997) and antenatal violence is associated with an increased risk of child behavioural problems (Flach 2011).
Description of the intervention
There are a number of interventions that have been examined in relation to violence prevention for pregnant women. A review by Sharps 2008 suggested that perinatal home-visiting programs are likely to reduce the incidence of physical abuse and improve pregnancy and infant outcomes. Several studies show that interventions such as wallet-size cards with community resources listed, spending time in a shelter, individual counselling, and home social support programs, alone or in combination, may decrease physical abuse (McFarlane 2006; Parker 1999). A review focusing on women recruited in DV shelters or refuges suggests that intensive advocacy may reduce physical abuse one to two years after the intervention (Ramsay 2009). There is currently no systematic review examining interventions specifically focusing on pregnant women.
During routine prenatal checkups, the clinician has the opportunity to screen women and then refer to various intervention programs. For women, both screening and intervention programs could lead to referral of identified individuals to appropriate healthcare specialists or agencies for support such as referral to social workers, shelters, counselling or other community-based resources. For partners, referral can be made to batterer treatment programs. The effectiveness of these programs is not clear (Arias 2002).
Available studies to date have investigated the effectiveness of DV screening on reduction of violence or improving women's health outcomes (Feder 2009; Nelson 2012; Spangaro 2010), but these studies have not investigated pregnancy outcomes.
It is clear that unless DV risk is reduced, screening efforts are of little use. Thus reviews investigating the effectiveness of screening alone are relevant to the topic in hand and worth mentioning. Acceptability and effectiveness of screening for women presenting in prenatal clinics has been studied (Ramsay 2002) and findings suggest that screening programs in antenatal clinics generally increased rates of identification of women experiencing DV. More recent studies provide evidence that universal screening is associated with improved pregnancy outcomes (Coker 2012 ). Screening programs that took a comprehensive approach (i.e., incorporated multiple program components, including institutional support) were successful in increasing DV identification rates (O'Campo 2011). This evidence suggests that screening for DV may be a useful component of routine antenatal assessment (Janssen 2006).
How the intervention might work
Often, the goal of intervention is to reduce further abuse. Some interventions are designed to improve women's empowerment and to enhance their independence and control. Some attempt to keep women from danger of extreme violence and teach women how to stay safe. Generally, safeguarding women from harm, managing symptoms, conducting a safe communication with others when in an abusive relationship, increasing women's confidence, and improving family networks and relationships are the major objectives of interventional programs (Ford-Gilboe 2011). Healthcare providers may make positive contributions to women's access to special services designed to reduce violence. These interventions may reduce women's exposure to violence and more generally improve women's health (Kramer 2004; McCloskey 2006). Reducing the contact between partners in violent relationships also reduces opportunities for further abuse and potential harmful activities (Dugan 2003).
Why it is important to do this review
Current literature on the subject is inconclusive (O'Reilly 2010). Some reviews have concluded that there is insufficient evidence to show whether or not interventions or screening are effective (Nelson 2012). Conversely, Horiuchi 2009 has suggested that screening and interventions for pregnant women would be beneficial. It is therefore necessary to obtain a more comprehensive review of the existing evidence to identify the benefit or harm attributed to commonly practiced interventions to prevent or reduce DV.
Moreover, pregnancy is a unique window of opportunity to screen for DV. Women may welcome the opportunity to be asked about DV (Gazmararian 1996), although they need to be able to trust the care giver and be assured of confidentiality of the information exchanged (Gazmararian 2000). Healthcare professionals are in a unique position to identify and assist women during pregnancy.