Domestic violence

Domestic violence in pregnancy

By Rachelle Drouin, Founder, Women's Web

Pregnancy is a supposed to be a joyful time—a time of peace and safety. A woman's preoccupations turn to her unborn child, toward nurturance, toward the next generation. She hopes to raise a healthy child.

For many women, pregnancy marks the beginning of a turbulent and violent time. It's estimated 1 in 5 women will be abused during pregnancy. Even more alarming—as the murders of Liana White and Laci Peterson suggest—homicide during pregnancy now surpasses automobile accidents and falls as the leading cause of death.

How prevalent is domestic violence?

A May 2002 report by the United States Accounting Office to the Honorable Eleanor Holmes Norton, House of Representatives, on pregnant victims and the effectiveness of prevention strategies states that "of surveyed women who reported being raped or physically assaulted since the age of 18, about three quarters reported being victimized by a current or former spouse, cohabiting partner, or date."

In a 1993 Statistics Canada survey of 12,300 adult women, 29 percent of the women who had ever been married or involved in common-law relationships reported that they had been assaulted by their partners and 51% reported at least one incident of physical or sexual violence since the age of 16.

How prevalent is domestic violence in pregnancy?

Women in abusive relationships may hope pregnancy will reform an abusive partner. The sad reality, however, is that pregnancy is more likely to have the opposite effect: 1 in 6 abused women reports that her partner first became abusive during pregnancy. According to the Center for Disease Control, at least 4 to 8 percent of pregnant women—that's over 300,000 per year—report suffering abuse during pregnancy. Even more alarming: domestic violence is the leading cause of injury to American women between 15 and 44 and is estimated to be responsible for 20 to 25 percent of all hospital emergency room visits by women.

What constitutes abuse?

Pregnancy, while it's cause for excitement and elation, causes stress is any relationship and in many cases, it's a trigger for domestic violence.

The Center for Disease Control defines domestic violence during pregnancy as "physical, sexual, or psychological/emotional violence, or threats of physical or sexual violence that are inflicted on a pregnant woman." In a household survey cited in "Battering and Pregnancy" (Midwifery Today 19: 1998), it was found that pregnant women are 60.6 percent more likely to be beaten than women who are not pregnant.

Victims often see abusive behaviors as isolated, unrelated incidents. Yet, a partner's good behavior now is not necessarily a good predictor of future behavior: if a partner strikes a woman once, he or she is likely to do it again. Domestic violence often follows a clear pattern, frequently described in one or more of the following ways.

1. Tension may arise within a relationship. It may be the result of a minor disagreement.
2. Tension continues to build over a period of hours, or days or perhaps months.
3. Something will trigger an abusive incident. This assault may be physical, psychological, or sexual. (See Types of Abuse.)
4. A period of calm follows. This is often called the "honeymoon phase." The abuser may buy his/her partner gifts or lavish attention on her, often feeling sorry for what has happened.
5. Over time, the above cycle changes. More small incidents will occur, tension will increase, and the cycle will begin again. Both partners want to believe incidents of abuse will not repeat themselves, but they usually do.

Domestic violence doesn't necessarily have to be physical. It's important to understand that abuse is a pattern of behavior in which physical violence and/or emotional coercion is/are used to gain and maintain power or control in a relationship. Abuse may be continuous, or it may be a single incident of assault. Abuse may be physical, sexual, psychological/emotional or economic. For instance, say Liz Hart and Wanda Jamieson, authors of "Responding to Abuse During Pregnancy" (an overview paper available from the National Clearinghouse on Family Violence), abusers may try to control, limit, delay or deny a woman's access to health care practitioners and pre-natal providers. They may also refuse sex on the grounds that the pregnant body is unattractive, refuse access to food, threaten to leave, or threaten to report her to child welfare authorities as a potentially unfit mother. They may refuse to support a woman financially during her pregnancy or birth, refusing to allow her access to money to buy food and supplies, or force her to work beyond what is reasonable for her current endurance.

It should also be noted that for some women, their very pregnancy may itself be a form of abuse: a pregnancy conceived through sexual assault, marital rape, or from the woman's inability to negotiate contraceptive use. In fact, a fact sheet produced by the Pan American Health Organization states that women whose pregnancy is unintended or unwanted are four times more likely to suffer increased abuse. In abusive relationships, women and young girls are often forbidden to use contraceptives. Often used as a form of coercion and control, this type of dominance may even be an abusive partner's way to commit the woman to the relationship through pregnancy. Just as an abuser may control a woman's decision to continue her pregnancy, he or she may intimidate a woman into having an abortion. Some abused women may choose to have abortions out of fear.

The effects of domestic violence on pregnancy

The effects of domestic violence on pregnancy

Abuse is harmful not only to the woman being abused, but also to her baby, particularly if she takes blows to the abdomen. Such attacks can cause fetal fractures and cause injuries to or ruptures of the pregnant woman's uterus, liver, or spleen.

Studies have shown that during pregnancy, an abuser's attacks will generally focus on the breasts, abdomen, and genitals, resulting in serious consequences on the mother, fetus, and newborn and giving rise to maternal mortality and morbidity. It's linked to an increased risk of miscarriage, low birth weight, fetal injury, and fetal death.

Other complications may include:

• uterine prolapse
• antepartum hemorrhage
• premature rupture of membranes
• premature labor
• abruptio placenta
• vaginal infection from forced or unprotected sex with someone who has an infection
• increased first and second trimester bleeding
• headache
• irritable bowel syndrome
• chronic pelvic pain
• increased risk of contracting a sexually transmitted disease or HIV/AIDS

The effects of domestic violence on labor

During labor and delivery, an abuser may try to control a woman's decision to have an epidural, pain medication, or other interventions. He may demand that doctors restore his partner's vagina to its pre-birth state and may make disparaging comments about her sexuality or about the sex of the baby following the birth.

For women with a history of sexual abuse, say Hart and Jamieson, labor and delivery can be especially difficult. As labor progresses, increasing pain, the resulting loss of control, and repeated pelvic and genital exams can lead to myriad responses from laboring women. Some may appear too quiet and passive while others may become overly controlling and demanding. Some may scream and cry, while others may suffer uncontrollable terror. Still others may dissociate during labor or delivery. To physicians, nurses and other attendants unaware of the abuse, such behaviors may be difficult to understand. Those who do have knowledge of a woman's history of abuse have speculated that abuse plays a role in inadequate fetal descent and may prolong second stage labor.

The effects of domestic violence after birth

Following delivery, an abuser may increase abuse, use a woman's relationship with her baby as a weapon, and deny her access to the baby. He or she may:

• sulk or put her down when she spends time with the baby
• fail to support her or to help with the baby
• demand sex soon after birth
• make negative comments about her sexuality, attractiveness, and appearance
• blame her because the infant is the "wrong" sex
• put down her parenting ability
• threaten to or actually abduct the baby
• tell her she will never get custody of the baby
• make her stay at home with the baby
• prevent her from taking a job
• make or threaten false child abuse accusations
• withhold money for supplies
• blame her for the baby's crying
• force her to or forbid her to breastfeed

Because abuse undermines their sense of competence and confidence, the World Health Organization believes abused women may not be able to breastfeed successfully.

Signs of abuse

Domestic violence isn't restricted to women of a particular race, religion, education, class, or sexual orientation. Abused women come from all backgrounds and socioeconomic areas. Yet, because of a fear of reprisal, embarrassment, and ignorance of shelters and sources of financial assistance, many victims are afraid to disclose their abuse. Such factors make it difficult to determine who has been abused. It's therefore important for professionals and practitioners to know how to appropriately respond to these issues. (Professionals' response is addressed later in this article.)

Signs a pregnant woman has been or is being abused may include:

• a delay in seeking pre-natal care
• reluctance or refusal to attend pre-natal education
• unexplained bruising or damage to her breasts or abdomen
• continued use of or addiction to substances such as cigarettes, drugs or alcohol—all known to be harmful during pregnancy
• recurring or unexplained psychosomatic illnesses
• history of physical illness

Responding to abuse

How do victims typically respond?

Devastating as domestic violence is, victims of abuse often respond in equally devastating ways, engaging in self-destructive behaviors (such as alcohol and substance abuse) that risk harming both themselves and their baby. Because abusers maintain control of their victims through socially isolating them, abused women are often unable to access the support of family, friends, local services and statutory agencies. Embarrassed that their intimate partner is an abusive person, many will not seek out medical attention, attend pre-natal classes, or attend post-natal care. In addition, because of the heavy toll of domestic abuse on victims' self-esteem, victims may also suffer from depression, anxiety, panic attacks, eating disorders, and an increased dependence on their abuser. Some may even attempt—and sadly, achieve—suicide as a means of escaping an abusive situation.

In Hart and Jamieson's overview paper, "Responding to Abuse During Pregnancy", one victim describes the psychological impact of domestic violence thus:

The body mends soon enough. Only scars remain?but the wounds inflicted upon the soul take much longer to heal. And each time I relive these moments, they start bleeding all over again. The broken spirit has taken longest to mend; the damage to the personality may be the most difficult to overcome.

It's important not to overlook the other victims of domestic violence during pregnancy: that is, child witnesses to violence against their mother. Children who witness acts of violence may experience serious psychological or behavioral effects, including:

• increased acting out and aggressive behavior
• depression, anxiety, or panic attacks
• nightmares and sleep disturbances
• problems with social development
• problems at school (truancy, poor grades)
• post-traumatic stress disorder
• bedwetting
• separation anxiety
• inappropriate attitudes about violence
• self-blame

How should professionals respond?

Professionals can mean any number of persons able to offer help to an abused woman or refer her to appropriate sources of support. Professionals, say Hart and Jamieson, can denote physicians, nurses, pharmacists, counselors, therapists, social workers, health educators, police and emergency personnel.

Because of their tendency to miss pre-natal and post-natal appointments, abused pregnant women are sometimes seen by practitioners as deviant, time wasting, or self-absorbed. It's important for professionals to keep a grounded perspective and to be sensitive to the many issues faced by victims of domestic violence.

A paper commissioned by the College of Family Physicians of Canada's Maternity and Newborn Care Committee (January 2000) suggests that because of the prevalence of abuse in the general population, all pregnant women should be screened for past or current history of abuse. These questions, however, should never be asked in the presence of their domestic partners. Professionals should be particularly concerned where a woman's partner appears overly solicitous, prevents her from seeing professional in private, or does not allow her to answer questions for herself.

Because of shame, embarrassment, uncertainty about housing options and the availability of financial aid or because previous attempts at disclosure were met with disbelief or denial, women may be reluctant to disclose their abuse. Clinicians, too, may be afraid to ask about abuse because of a lack of understanding of the importance of domestic violence as a health and social issue. Practitioners' own experiences—as victims, perpetrators, or child witnesses—could also impact their readiness to broach the subject of abuse. As a result, professionals need to recognize and address how their values and personal experiences may affect their ability to respond appropriately.

Minimizing the seriousness of the abuse or questioning a victim's behavior and responses during abusive episodes are not appropriate responses. The important thing is that professionals respond in a manner that makes victims feel believed and supported. The importance of having a safety plan should be stressed. In addition, women will feel more comfortable disclosing if they are assured the details of their disclosure will remain confidential.

Some women may need help in making wise choices and in sorting out their past experiences of abuse. In addition to providing clinical care, health care providers should also be concerned with helping such women with their physical and psychological symptoms, referring them to other health care professionals or to community services for help in securing shelter, sorting out financial and legal options, and arranging further counseling for themselves and if applicable, for their children.

Where an abused woman has children, practitioners should ask whether they have ever been abused or if there is risk of abuse. Equally important, professionals should also determine whether the physical and emotional environment is safe for the children. If not, any concerns for their safety should be reported to the appropriate child protection services.

Where an abused woman has children, practitioners should ask whether they have ever been abused or if there is risk of abuse. Equally important, professionals should also determine whether the physical and emotional environment is safe for the children. If not, any concerns for their safety should be reported to the appropriate child protection services.

Professionals need to thoroughly document the abuse.

If someone you know is being abused…

If you believe someone you know is in an abusive relationship, share your concerns and ask how you can help. Domestic violence is a crime, punishable by law. No one deserves to be abused. Remind your friend or family member that the abuse is not her fault and that she is not alone. Encourage her to seek support and counseling from local services. Encourage her to talk to an advocate, help her devise a safety/escape plan, and encourage her to talk to a healthcare professional. Try to be as supportive and non-judgmental as possible: it's important to understand the effects of abuse and the myriad emotions (embarrassment, shame, self-recrimination, disorientation) experienced by victims of domestic violence—feelings undoubtedly amplified by pregnancy.