Midwives Role in Domestic Violence Essay

Domestic violence has been with us throughout the ages. A brief overview of the subject shows that it has taken many forms and significantly, we note that the phenomenon is defined in many different ways. To an extent, these ways are determined by the society, the environment and to an extent the chronological time of the events. Acts and behaviour patterns which can be considered acceptable in one social construct can be completely unacceptable in another. We can cite an example enshrined in British law, that up to 1824 a husband was legally entitled to beat his wife to any degree as long as he did not use a stick that was larger in diameter than his thumb, hence giving rise to the expression “rule of thumb” (Boyle A et al. 2004). Midwives Role in Domestic Violence Essay

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Studies have shown (DOH 2000) that women who are abused experience an average of 35 episodes of domestic violence before they make the decision to seek help. The same study details the many and varied ways that women will ask for help. Some are clearly unequivocal and overt by reporting to the police, the social worker or some other statutory representative or healthcare professional, while others may not present overtly and the signs of abuse may be noticed by another person who then intervenes and may thereby represent a channel of communication that may be what the victim has been waiting for. A third group appear to enter a phase of complete denial. They may present to a healthcare professional with signs and symptoms that are highly suspicious of domestic violence, but when challenged, may deny the possibility and produce a string of plausible explanations as to just how certain injuries had been sustained. (Yura H et al. 1998). As with any situation that affects the human condition there are inevitably a spectrum of other presentations behind these extremes and although we have chosen to present three particular stereotypes, we note that each individual case is unique, has its own unique trigger factors and response patterns, but is almost universally distressing and degrading to the victim of such violence. In the circumstances that we are considering here the case is rather different from the majority insofar as we are specifically considering the role of the midwife in dealing with domestic violence. It follows from this that violence towards the mother not only affects her but potentially can cause both direct and indirect morbidity with the unborn or newborn child. There is also the effect that it can have on any other children in the family, but we shall discuss these issues in greater detail in the review itself.Midwives Role in Domestic Violence Essay

The whole topic of domestic violence has been given a degree of prominence in recent years with bodies such as the American College of Emergency Physicians (ACEP 1996)  and their British counterpart, the BAEM, (BAEM 1993)
issuing protocols and guidelines relating to suspected domestic violence and the British Government launching a number of initiatives which are specifically directed at targeting the whole area of domestic violence and also at helping to support the victims of such violence.

Methodology

The method which was adopted for this particular review was to take the initial step of both considering and reflecting on the title, and the implications of the title, for a short period of time and to read through some relevant general literature surrounding the subject in order to get an overview of the whole area. (Dempsey P A et al. 2000).  Shortly after this, further reading was done to encompass the areas of the research patterns that had emerged historically in this area. (Vickers, A. J et al. 2001). This was done over a period of about two weeks and covered about 40 different texts. During this period appropriate references were noted and cited papers were located, read and recorded. Some computer sources including CINAHL, MIDIRS and OVID, together with the Cochrane Data base, were accessed for further background (and in some cases specific)  information. The computer sources were not directly utilised in the preparation of the review itself, as the main basis of the literature used was accessed in hard copy from both the local Post- Graduate centre and also the local University library (client: you might like to personalise this) where the databases for appropriate literature on the subjects could be searched and retrieved together with peer-reviewed journals. (Macnee C L 2004). It should be noted that the majority of papers retrieved and consulted were from UK based peer reviewed journals and UK based authors, but a number were from international sources. As a general rule, the primary searches were done using material that was not more than 10 years old, although some older papers were consulted when it was necessary to put particular points into a historical perspective.  (Rees C 2003)

Approximately 45 papers were both read and assimilated in the preparatory stages of this review, both in the area of domestic violence and in the area of specific midwife involvement in the investigative process. Further papers were read in the area of critical analysis of peer reviewed literature. In total, over 120 papers were consulted in the preparation of this review. The evidence was assembled and assessed in a critical and dispassionate form and them the most relevant portions were presented in a logical fashion in the final review. ( Berwick D  2005)Midwives Role in Domestic Violence Essay

Having been able to assess and present the available evidence, it then became possible to take a view on the evidence base thus collected, a summary made and conclusions reached. The conclusions and summary were then used to establish where there were gaps in the literature. (Hek G et al. 2000).  This allowed for a number of further conclusions relating to the direction of necessary research in the area.

Review

If we consider the literature on the subject of domestic violence it quickly becomes apparent that the spectrum of domestic violence, at least in terms of definition, is huge. Different papers appear to define and describe the phenomenon in quite different and disparate ways. Boyle (A et al. 2004) details “abuse, intimate partner abuse, interpersonal violence, wife battering, or violence against women” as being some of the terminology that is in common usage for the phenomenon and also highlights the consideration that other terms such as  “wife beating and violence against women”  are also commonly accepted synonyms for the phenomenon but should be regarded as very unsatisfactory for the process in general terms, as it directly implies that the violence is a one way phenomenon from a man directed against a woman. While it is true that this type of assault constitutes the overwhelming majority of cases, one must not overlook the possibility of domestic violence directed against men from their female partners and also against both men and women in homosexual relationships. (Mcleod M 1984).
Another confounding factor which becomes apparent when making any degree of critical appraisal of the literature, is the fact that there appears to be a considerable disparity in the definition of how one can define the perpetrator in domestic violence situations.Midwives Role in Domestic Violence Essay How, for example, does one categorise the male victim of domestic violence if he is being attacked in retaliation for previous assaults on his wife?  Boyle cites two opposing definitions as an example to illustrate the point. The Coker study (Coker A l et al. 2000) only categorised an incident as “domestic violence” if the perpetrator had been having intimate relations with the victim for more than three months whereas, by contrast the Tham study (Tham S W et al. 1995), defines the perpetrator as “someone who might have been expected to be supportive”. The two definitions being clearly miles apart in terms of reflection of the relationship between the offending parties and thereby making meaningful comparison between papers very difficult.  In the same way we can point to any number of papers which define domestic violence as physical assault where as a significant proportion of what may be more appropriately called domestic abuse may have a psychological, financial or even a purely verbal element in it, but it can still contribute to a significant amount of psychological trauma in the victim of such an arrangement. As we have commented in the introduction there is also the element  of “collateral damage” to other members of the family who may witness domestic violence  even though it may not be directed overtly at them. We shall discuss the “psychological erosion” effect that such witnessing may have on children in the family and how it may appear to “legitimise” this behaviour in their eyes and how it may subsequently manifest itself in a belief that in later life violence is an appropriate ploy to settle intra-family disputes.

If we consider a comparatively recent study by Mirrlees-Black (C 1999), we can point to a substantial evidence base that suggests that domestic violence in the sense of physical violence is more often than not perpetrated by a comparative stranger, the more subtle forms of psychological and financial abuse are more likely to be perpetrated by a “significant other” with a closer and more intimate relationship than overt violence.Midwives Role in Domestic Violence Essay

If we accept all of these caveats and consider the aetiology of domestic violence in general terms, a number of different authorities point to a number of different factors which appear to be significant in the genesis and perpetuation of the abusive and violent situation. Boyle suggests that controlling behaviour in the perpetrator is significant and Dearwater (S R et al. 1998) suggests a crescendo scenario starting from verbal abuse stemming from a failure of respect on the part of the perpetrator, which can then escalate into one of the other forms of controlling behaviour patterns. Controlling behaviour can be considered as economic control as well as physical control.
For a definitive and considered general statement on the issue we can look to the World Health Organisation who has defined violence as:

…the intentional use of physical force or power, threatened or actual…that either results in, or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation (WHO 1996)

If we consult the literature for an appreciation of the incidence of domestic violence, we immediately face the problem (quite apart from that of actual definition cited above) of knowing the extent of domestic violence that is unreported. Clearly we can cite figures that reflect the number of cases that are reported to the police or are suspected at the A&E departments across the country, as these are figures that are routinely collected and are in the public domain. Abbott (J et al. 1995), in trying to understand the degree of the problem, undertook a large cross sectional study and commented on the reluctance of many victims to disclose significant information. Their study (albeit American based) suggested that 11.7% of women who attended the A&E Depts. included in their study,  were attending because of either injuries or stress directly referable to domestic violence in one of its many forms. Of all the women seen in the A&E Depts., 2% were there as a direct result of physical trauma sustained  directly from an abusive relationship, and this particular study suggests a staggering 54.2% lifetime prevalence rate for domestic violence in the populations of women who were seen in the A&E Depts. during the period of the study. Midwives Role in Domestic Violence Essay This may well reflect the comments made in the opening paragraph of this review that the degree of domestic violence is as much a factor of the culture of the perpetrator and definition of the act as much as any other factors. This is illustrated  by consideration of a comparison with a similarly constructed UK study (Boyle A A et al. 2003) which found that 1% of women attending the A&E Depts in the study were there as a direct result of direct physical violence and the same authors calculated the overall lifetime prevalence rate for domestic violence in this population to be in the region of 22%.   This second set of figures is more nearly in keeping with the majority of other studies in the area (viz. Dearwater S R et al. 1998).

A smaller Scottish study (Wright J et al. 1997) considered an A&E dept seeing 60,000 cases per year and found 19 cases of overt (incontrovertible) domestic violence in a two month period. Another factor which may be considered to be implicit in the term “domestic violence” is the fact that the violence is considered to have occurred in the home. This is not universally the case. A rather older study (Fothergill N et al. 1990) found that between 15% and 20% of cases of assault occurred at sites away from the victim’s home. One of the overriding factors that must be considered in any type of critical analysis of the figures is that part of the apparent disparity in both incidence and prevalence is due to the structure of the studies. There appears to be a distinct overrepresentation of victims of domestic violence in the populations that present to A&E Depts. If we compare these figures with those obtained from more community based studies such as the British Crime Survey (cited in Mirrlees-Black C 1999) we find that lifetime prevalence figures are in the region of 26% for women and 17% for men and annual prevalence figures in the same study are quoted as 5.9% and 4.9% respectively.Midwives Role in Domestic Violence Essay

We have made mention of some of the demographic elements earlier. If we consider these in rather more detail, we can point to studies (Roberts G L et al. 1996) which suggest that, (again in a population of A&E Dept attenders), over 15% of men had experienced at least one episode of domestic violence in their lives and this was approximately half that of a similar group of women. Factors that were found to be independent risk factors for the risk of domestic violence include lack of education, alcohol misuse, unemployment, low income, and recreational drug use (Kyriacou D N et al. 1999).
In specific consideration of our investigation in the role of the midwife in the issue of domestic violence, we note that there was a widely reported study which suggested that being pregnant was also an independent risk factor for abuse (Gelles R J 1988). This was considered to be a landmark study in the area at the time of its publication, but we note that other reputable and carefully constructed studies have failed to replicate the original author’s findings. (McGrath M E et al. 1998. Other relevant factors include comparative youth as a risk factor and there are also studies that suggest that post-partum status carries a higher risk of domestic violence than does antenatal status. (Gazmararian J A et al. 1996). The same study also provides evidence to support the view that both the severity and the frequency of attacks of overt physical violence appears to escalate as pregnancy progresses and passes to the post natal period reaching a peak at between 6-9 months post partum.
In terms of identification of the potential victim of domestic violence the midwife (or other healthcare professional) should be alert for a number of signs and symptoms that have a high index of suspicion for domestic violence. (Staquet M J et al. 1998). Midwives Role in Domestic Violence Essay Different studies have identified different characteristics of the abused partner but there are a number of common factors which appear to be reasonably consistent throughout the major studies of the subject.

The most common consensus is that the victim will tend to demonstrate an increased usage of healthcare facilities. In general terms Bergman (B et al. 1991) is typical in this regard and documents an increased utilisation of all forms of medical care, most notably hospital admission which were found to be four times higher in this group than the admission rate in the general population.  even though we must accept that in the figure derived for the “general population” there will inevitably be an unknown, but probably significant, number of undetected cases of victims of domestic violence. Intuitive examination of the issue might suggest that there would be an increase in the usage of the psychiatric services and indeed, the same study points to a higher utilisation of facilities that are associated with alcoholism, depression and also deliberate self harm in the victims of domestic violence group. In terms of the index of suspicion for the visiting midwife, the authors suggest that women who present with multisystem, frequent and poorly defined complaints should be regarded as being the most likely to have an underlying problem with domestic violence, even they may not wish to overtly communicate this fact top the healthcare professional, it should be regarded as a significant warning sign.Midwives Role in Domestic Violence Essay

Other studies point to other warning signs. We have already commented upon the likelihood of repeated attendance being associated with domestic violence, but interestingly, one study. (Spedding R L et al. 1999) suggested that the time of presentation was also significant. For reasons that the authors did not enlarge or speculate on they found that assaulted women were more likely to present between 6 pm and 6 am when compared to those with unintentional injuries.
There is considerable discussion and debate in the literature related to whether these traits and characteristics suggest a causal or resultant relationship between observed symptomatology and the situation of domestic violence. On an intuitive level one can postulate that being the victim of domestic violence or being in a long-term abusive relationship may be sufficient cause to present to a healthcare professional with depression, and could easily lead to episodes of deliberate self harm equally Wadman (M C et al. 1999) considers the possibility that the personality traits that can be frequently associated with both a depressive personality and also the tendency to deliberate self harm, may also “confer an increased risk of entering an abusive relationship”. Examination of the current literature on this element does not help us to reach any clearer view on the issue other than to allow us to present the fact that there is clearly a dichotomy of opinion on the subject.
In specific regard to issues surrounding pregnancy we can also note that there is evidence to suggest that violence can be specifically related to such issues. (CMO 2000).Midwives Role in Domestic Violence Essay Of all the women who died in a three year period (‘97-’99) with a death related to pregnancy, 12% had reported domestic violence at some stage prior to their death. The study did not make any direct observation (because it couldn’t) of a direct link between domestic violence and the death.

Methodology

The method which was adopted for this particular review was to take the initial step of both considering and reflecting on the title, and the implications of the title, for a short period of time and to read through some relevant general literature surrounding the subject in order to get an overview of the whole area. (Dempsey P A et al. 2000).  Shortly after this, further reading was done to encompass the areas of the research patterns that had emerged historically in this area. (Vickers, A. J et al. 2001). This was done over a period of about two weeks and covered about 40 different texts. During this period appropriate references were noted and cited papers were located, read and recorded. Some computer sources including CINAHL, MIDIRS and OVID, together with the Cochrane Data base, were accessed for further background (and in some cases specific)  information. The computer sources were not directly utilised in the preparation of the review itself, as the main basis of the literature used was accessed in hard copy from both the local Post- Graduate centre and also the local University library (client: you might like to personalise this) where the databases for appropriate literature on the subjects could be searched and retrieved together with peer-reviewed journals. (Macnee C L 2004). It should be noted that the majority of papers retrieved and consulted were from UK based peer reviewed journals and UK based authors, but a number were from international sources. As a general rule, the primary searches were done using material that was not more than 10 years old, although some older papers were consulted when it was necessary to put particular points into a historical perspective.  (Rees C 2003) Midwives Role in Domestic Violence Essay

Approximately 45 papers were both read and assimilated in the preparatory stages of this review, both in the area of domestic violence and in the area of specific midwife involvement in the investigative process. Further papers were read in the area of critical analysis of peer reviewed literature. In total, over 120 papers were consulted in the preparation of this review. The evidence was assembled and assessed in a critical and dispassionate form and them the most relevant portions were presented in a logical fashion in the final review. ( Berwick D  2005)

Having been able to assess and present the available evidence, it then became possible to take a view on the evidence base thus collected, a summary made and conclusions reached. The conclusions and summary were then used to establish where there were gaps in the literature. (Hek G et al. 2000).  This allowed for a number of further conclusions relating to the direction of necessary research in the area.Midwives Role in Domestic Violence Essay

 

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