Identifying and Including expectant and new mums experiencing domestic abuse.

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Identifying and Including expectant and new mums
experiencing domestic abuse.

• Eileen Maloney Specialist Midwife. Alison Wales
  Senior Psychologist
• October 2005

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Aims of the presentation

• Raise Awareness of Domestic Abuse
• Quiz-- Group Activity
• Statistics
• Research Evidence
• D.A in Pregnancy/risks/reasons
• Asking the ? What do we do then
• Effects of D.A. on children
• Government Goals Interventions in Stockport

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Domestic Violence and Abuse

• Physical
• Sexual
• Psychological
• Emotional
• Financial
• Any incident of threatening behaviour, violence
  or abuse, between adults who are or have been
  intimate partners or family members, regardless
  of gender or sexuality.
• (Home Office)

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Physical Abuse

• Physical injuries bruises, abrasions, fractured
  bones, lost teeth, internal injuries, burns
  gynaecological problems.
• He beat me so badly that I lost a baby and had
  to have another terminated (Nikita, 2004)
• Once it starts it never stops I really dont
  think they ever change Andrew was a big man
  massive. I had my nose broken 5 times and had to
  have operations I got a fractured ankle and
  black eyes, my coccyx cracked when he threw me
  onto the floor (Helen, 2004)

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This was my life. Getting hit, waiting to get
hit, recovering forgetting. Starting all over
again.Roddy Doyle The Women Who Walked Into
Doors (1996)
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Psychological and Emotional Abuse (Duluth Power
and Control Wheel)

• Intimidation - destruction of personal property,
  abusing pets
• Constant criticism and belittling comments
• Isolation and control of contact with family and
  friends
• Minimising, denying and blaming
• Using children
• Using male privilege
• Oppressive control of finances
• Coercion and threats

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I provoked him. I always provoked him. I was
always to blame I should have kept my mouth
shut. But that didnt work either. I could
provoke him that way as well. Not Talking.
Talking. Looking at him. Not looking at him.
Looking at him that way. Not looking at him that
way. Looking and talking. Sitting, standing.
Being in the room. Being. Roddy Doyle The
Woman Who Walked Into Doors (1996)
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• Hes always in my head all the time (Marie,
  2004)
• I used to predict his every mood I couldnt
  even open my mouth (Helen, 2004)
• He used to go on about my weight and call me
  You fat slag(Terry, 2004)

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Biggest Challenges

• Changing Perceptions
• Challenging Cultural acceptances
• Working with Pink elephant
• Providing a committed and consistent change in
  the way the health service responds

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Who does it concern?
Anyone can experience domestic violence/abuse
Children and Young People are also affected by
domestic abuse.
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Quiz

• Group Activity

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Domestic Abuse In Stockport
Reported domestic violence incidents in
2004/2005 (est.12 reported to Police (HO)
85have children) Estimated unreported
incidents Total demand for refuge per year due
to DA Stockport Womens Aide accommodation
capabilities per year Cost of Domestic Abuse a
year (public services and economic output loss in
England and Wales) Cost a year in Stockport
4,061 29,780 732 60 to 100 5.7 billion
31,658,000
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National Local Statistics

• Nationally it is estimated that 1 in 4 women
  will, during their lifetimes, experience domestic
  abuse and 2 women are killed by
  partner/ex-partner every week.
• 2004 gt110,000 incidences reported to Met Police
  London. 29 murders
• Jan - July 2005 11murders to date and 75 of
  children on at risk register.
• Within Stockport Social Services, domestic
  violence is the most frequently cited reason for
  referral to Childrens Services

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Statistics relating to Domestic Abuse and
Children

• In nine out of ten cases, children are present in
  the same or next room while violence is going on
• In half the cases of violence between adults
  there is violence against children too.
• In 33 of Child Protection cases there is a
  history of domestic violence towards the mother

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COSTS OF DOMESTIC ABUSE

• Costs to the NHS
• Physical Injuries 1.2 billion
• Mental Health Care 176 million
• To the State 3.1 billion
• To the employers 1.3 billion
• Human Suffering 17 billion (Walby 2004)

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Evidence

• Position Papers recommendations from the Royal
  colleges including the RCM encouragement from
  Dame Karlene Davis(2004)
• Resource Manual(2000)
• Childrens NSF/Maternity(2004)
• Into the Mainstream(2002)

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Confidential Enquiries

• CEMD 1994-96 (6 deaths by Partner/ Ex partner)
• CEMD 1997-99 (8 women murdered2 died due to
  medical conditions arising from DA.
  12 of 378 who died
  voluntarily reported violence to HP in pregnancy.
  None of the women who died were asked
  routinely.Hence underestimation.
• CEMACH 2000-02(11women murdered by Partner/ Ex
  partner 1died later after del. Another 43
  voluntarily reported DA or were known to be in an
  abusive relationship. 55 represents 14 of the
  391 women

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Every Child Matters - Joint Area Review

• The impact of Domestic Violence directly
  contributes to the 5 ECM outcomes,
• being healthy
• staying safe
• enjoying and achieving
• making a positive contribution
• economic well being
• Domestic Violence has a direct impact on
  behavioural and emotional well-being, and the
  effects on their cognitive abilities and
  attitudes.
• They are also affected by disruption of
  community, family and friendship networks, moving
  schools, and often losing their homes and
  possessions.

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Domestic Abuse in Pregnancy

• 33 of domestic abuse starts in pregnancy
• Often domestic abuse escalates in pregnancy
• The risk of violence seems to be greatest in
  pregnancy and after the birth.
• One study found that 15 of women were assaulted
  in the first four months.
• And 17 were physically abused during the last
  five months of pregnancy.
• Being pregnant may serve to increase
  vulnerability rather than affording any
  protection from violence.

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Risk factors for DA in pregnancy

• Partner always present/speaks for the woman
• Repeated miscarriages/APH/PROM/UTI/STD
• Premature labour/SB/Ruptured Uterus/liver/Spleen
• Recurrent admissions AE/ Mat wards/ GP/MW
  clinics
• Late bookers/DNA
• Psychological-depression/anxiety low self esteem/
  nervous/shy/

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Drugs Alcohol
DOMESTIC ABUSE
Coping Mechanism for victims - (including
children) (helps to deal with emotional /
psychological effects)
Abuse is often fuelled by alcohol
DRUGS ALCOHOL
Continual use of drugs require the individual
to commit crime to fund the use
CRIME
Typically this involves theft from homes, shops
and individuals
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Reasons for violence in pregnancy.

• Jealousy of the unborn child and feelings of
  exclusion
• Attempts to end the pregnancy
• Anxiety concerning the womans contact with
  health professionals.
• Accusations of infidelity
• Increased vulnerability

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Empowering Environment

• Clear public messages - posters
• Information cards for staff and women
• DA Helpline tel. no inscribed on the inner front
  cover of handheld notes.
• One method-- Raise the issue with all women and
  provide information irrespective of disclosure.
• No Stigma
• Respect Privacy

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Risk Assessment Tool

• Separation
• Pregnancy/new birth
• Escalation
• Cultural isssues/sensitivity
• Stalking
• Sexual assault

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Support for Midwives

• Midwives have knowledge but may perceive DA as
  difficult in practice terms
• Support via SOM, Staff councillors,OH.
• Open door , Clinical Supervision
• Training in recognition of DA/ Role Play
  Awareness of how to Signpost etc.
• National policy/local guidelines
• Innovative projects

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Midwives Direct Routine Questioning

• Is an independent interpreter present,if
  required?
• Is the woman alone? If yes proceed I am sorry if
  you have been asked...
• Stipulate anything you say is confidential unless
  there are child protection concerns.
• As an adult have you been emotionally or
  physically abused by your partner or someone
  close to you?
• Within the last year,have you been hit
  slapped,kicked,or otherwise physically hurt by
  someone? If so,by whom? Total no of times?
• Since you have become pregnant (or during your
  pregnancy) have you been kicked,slapped,hit or
  otherwise physically hurt by someone?

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Non-Disclosure /Disclosure

• Information provided re local services
• Record Keeping (Handheld notes versus central
  file)
• Disclosure Listen to what the woman wants. Is
  she safe? Is she ready to leave or ? Going to
  remain in the relationship?
• Are there Child Protection concerns
• Signpost if appropriate. Offer HO leaflet
• Offer Support. Be an advocate

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Record Keeping

• Document disclosure in central file.
• NMC Guidelines. Record facts
• May form part of the future protection for the
  woman used as evidence in court of law.
• Avoid making Judgements

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Ways of Escalating Danger (Medical power and
control Wheel based on P C E wheel(DAIP Duluth)

• Violating confidentiality
• Trivialising minimising the abuse
• Blaming the victim
• Not respecting her autonomy
• Ignoring her need for safety
• Normalising victimisation

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Midwife Acting as Advocate(based on Power
Control Equality Wheel developed by D.A.
Intervention Project Duluth)

• Respect Confidentiality
• Believe and validate her experiences
• Acknowledge the injustice
• Respect her autonomy
• Help her plan for future safety
• Promote access to community services

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D.A incidents involving Police

• Who is in the household
• Who is informed
• Details of incident
• What do I do
• What does the midwife do

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Examples of ? /Statements (found to be useful in
instances of DA)

• How are you feeling?
• Is everything all right at home?
• Are you getting the support needed at home?
• Are you in a relationship in which you were
  treated badly? In what ways?
• I notice that you have a number of bruises,could
  you tell me what happened.Did someone hit you?
• Sometimes people tell me that they have been hurt
  by someone close to them,could this be happening
  to you?
• Your partner seems very concerned and anxious.
  Was he/she responsible for your injuries?

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Psychological Effects of Domestic Abuse on mothers

• Psychological and psychiatric problems-
  depression, anxiety, PTSD, suicide attempts (DV
  a factor in 1 in 4)
• I was so depressed I was nearly sectioned
  (Vicky, 2004)
• I was so scared of getting lost in my own mind
  (Chloe, 2004)
• I was pillow huggingjust sitting in the corner,
  screaming (Nikita, 2004)
• I was hospitalised. I didnt want to live I
  hoped I wouldnt wake up (Helen, 2004)

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Psychological Effects of Domestic Abuse on
Children

• Aggressive, violent behaviours
• Passive, withdrawn, overly compliant behaviours
• Psychosomatic/eating/sleeping problems
• Role Reversal (children are parentified)
• Educational / School Difficulties
• Relationship Difficulties
• Longer term effects depression / alcohol and
  drug misuse

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How are babies and young children affected by
Domestic Abuse?

• Death of the baby premature labour, miscarriage,
  forced termination.
• Sexual assault and rape of the pregnant mother.
• Poor foetal growth and effects on brain
  development
• Inability to develop secure attachments to
  parents
• Eating difficulties and failure to thrive in
  extreme cases
• Developmental regression (especially in toileting
  and language) (SOGSII results)
• Sleep disturbances

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How are babies and young children affected by
Domestic Abuse? Cont

• Receive physical injury
• Behavioural difficulties
• Fearful of new people and situations
• Frightened of perpetrator
• Distressed, confused, sad
• Too quiet, passive, less responsive
• Problems socialising / sharing
• Angry, aggressive, difficult behaviours

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Effects of Domestic Violence on mothers
parenting

• Reduction in mothers emotional availability and
  sensitive parenting (Maslows hierarchy)
• When I was with her dad, if she was crying a lot
  e.g teething, my nerves would be on edge cos of
  how hes react (Terry, 2004)
• I just kept up mainstream things feeding,
  bathingnothing else (Nikita, 2004)
• I was that busy concentrating on him- I used to
  feel sorry for the children (Helen, 2004)

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Interventions in Stockport

• The Health Service
• Stockport Domestic Abuse Forum
• (representatives from Police Domestic Violence
  Unit CAFCASS Probation Social Services,
  Education Welfare Youth Service, Education
  Psychology Womens Aid, Health Visiting Service
  Community Alcohol Team local solicitors
  Connexions Womens Centre Childrens Fund)
  aimed to set up multi-agency intervention Groups
• Young Children and Mothers Group
• Childrens Group
• SAFE Young Peoples Group
• Womens Group (Freedom Programme)
• Perpetrators Group

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The Freedom Programme (Pat Craven)

• understand the belief held by abusive men and
  recognise which beliefs they have shared
• recognise future abusers
• Gain self esteem self confidence
• Introduce to community resources
• greater understanding of the effects of DA on
  children
• Use F.P. in group setting or to enhance
  individual practice

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Young Children and Mothers Groups

• Pre-school children (pre-birth to 4 years) and
  their mums who have experienced Domestic Abuse
• Families known to Social Services and/or living
  in the Womens Refuge (visited at home / Refuge
  before groups started)
• Groups run for 7/ 8 weeks and have multi- agency
  staffing (specialist health visitor, senior early
  years psychologist, SSD family centre staff,
  womens aid worker
• Transport and lunch provided (funding from DAF)
• Next Group October 2005 at Brinnington
  Childrens Centre

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Childrens Group

• A support group for children who have been
  affected by Domestic Abuse
• Funded by Stockports Childrens Fund
• Children aged between 5 and 13 years
• Six weekly sessions after school at Womens
  Centre
• Transport and snacks provided
• Run by Stockport Womens Aid Child Support
  Workers
• Consultation from Senior EP

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Stockport Domestic Abuse Forum

• (DAF) is a multi-agency forum established under
  the remit of the Safer Stockport Partnership. (30
  members)
• The aim of the DAF is to work to prevent violent
  and abusive behaviour within partner and family
  relationships in Stockport.
• The Stockport DAF includes representatives from a
  wide range of organisations comprising statutory,
  voluntary, community and private areas of work
  and responsibilities.

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Government 5 key goals

• The Government identifies 5 key goals for 2005
• reducing the prevalence of domestic violence
• increasing the rate that domestic violence is
  reported
• increasing the rate of domestic violence offences
  that are brought to justice
• ensuring victims of domestic violence are
  adequately protected and supported nation-wide
• reducing the number of domestic violence related
  homicides.

Source www.crimereduction.gov.uk/domesticviolence
51.htm
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Guidelines from the Home Office

• Developing Domestic Violence Strategies
• A Guide For Partnerships Home Office, December
  2004
• Prevention and Early Intervention
• Protection and Justice
• Support for Victims
• Importance of Multi-agency work

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Legislation Domestic Violence Act

• The Domestic Violence, Crime and Victims Act 2004
  aims to
• increase the rights of victims and witnesses,
• ensuring they receive the help, support and
  protection they need.
• This builds on the Governments ongoing reform of
  the Criminal Justice System, re-balancing the
  process in favour of victims and witnesses.

Source www.crimereduction.gov.uk/dv01.htm
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Aim is for Equality (Non Violence)

• Non-Threatening Behaviour
• Respect
• Trust Support
• Honesty Accountability
• Responsible Parenting
• Shared Responsibility
• Economic Partnership
• Negotiation Fairness

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Useful contacts

• Stockport Womens Aid 01614774271
• Womens Aid National Domestic Violence Helpline
  08457023468
• Stockport Womens Centre 0161 355 4455
• Childline 08001111

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White Ribbon Day 25/11/05

• International Day Against Violence Against Women
• White Ribbon is a symbol of hope where women and
  girls can live free from violence.
• Wearing the ribbon is about challenging the
  acceptance of violence
• www.womankind.org.uk

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References

• Department of Health (2000) Domestic Violence A
  Resource Manual for Health Care Professionals,
  London, The Stationery Office
• Hester, M., Pearson, C. Harwin, N. (2000)
  Making an Impact Children and Domestic Violence,
  London Jessica Kingsley
• Caroline McGee Childhood experiences of Domestic
  Violence

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Any Questions

• Thank You for Listening