The impact of domestic abuse in the perinatal period

The Domestic Abuse Act 2021 defines domestic abuse as any act of abusive behaviour between personally connected people aged 16 years or over. The Act clarifies that ‘abusive behaviour’ could encompass isolated or repeated incidents of physical or sexual abuse, threatening, controlling or coercive behaviour, financial control and emotional abuse (e.g. belittling, manipulating and gaslighting.) People who are ‘personally connected’ could be intimate partners, ex-partners, family members or individuals who share parental responsibility for a child. There is no requirement for the victim and perpetrator to live in the same household.¹

Rates of domestic abuse are higher against people with mental disorders.^{Reference Howard, Trevillion, Khalifeh, Woodall, Agnew-Davies and Feder2,Reference Thomson, Nyein, Clarke, Tyrer and Khwaja3} Increasing evidence has found that people with severe mental illness are at high risk of being victims of violence in general, with 40–90% experiencing violence over a lifetime.^{Reference Khalifeh, Johnson, Howard, Borschmann, Osborn and Dean4} Pregnancy is a time when new mental disorders can develop and pre-existing ones can relapse, making pregnant women with mental disorders particularly vulnerable to experiencing domestic abuse. Thirty per cent of domestic abuse starts during pregnancy; where domestic abuse has already existed in a relationship, pregnancy causes its escalation. There is a high correlation between antenatal and postnatal violence.^{Reference Yapp, Oram, Lempp, Agnew-Davies, Feder and Trevillion5}

In some cases, the nature of domestic abuse may change during pregnancy as the perpetrator may make a conscious effort not to hurt the developing baby; instead, they will increase their controlling and emotionally abusive behaviours.^{Reference Callaghan, Morrison and Abdullatif6} Covert forms of psychological aggression (such as raised voices and insults) have been found to have a significant impact during pregnancy.^{Reference Perez, Stasik-O'Brien, Laifer and Brock7} It should be noted that the process of pregnancy and the birth itself are profound events that can be challenging for victims of sexual abuse.^{Reference Montgomery, Pope and Rogers8}

Reports from MBBRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) regularly investigate the causes of maternal deaths across the UK. A maternal death is defined as a woman who has died during pregnancy or up to 1 year after the end of pregnancy.

The prevalence of reported domestic abuse in England is 3.4% during pregnancy and 5.8% during the postnatal period.⁹ This is likely to be a gross underestimate, as MBBRACE-UK reports often state that data on domestic abuse are missing when reviewing cases of maternal deaths posthumously. Twelve per cent of the women who died during or up to a year after pregnancy in the UK in 2018–2020 reported being a victim of domestic abuse during their pregnancy.^{Reference Knight, Bunch, Patel, Shakespeare, Kotnis and Kenyon10}

Consecutive MBBRACE-UK reports have noted that women at ‘severe disadvantage’ are consistently over-represented among maternal deaths in the UK. The main elements of ‘severe disadvantage’ are a psychiatric diagnosis, substance misuse and being a victim of domestic abuse. Of the 495 maternal deaths in the UK between 2017 and 2019, 40 (8%) were of women considered to have ‘multiple severe disadvantages’ and all but 3 of these women had experienced domestic abuse.^{Reference Knight, Bunch, Tuffnell, Patel, Shakespeare and Kotnis11}

There are specific implications for an infant of a woman exposed to domestic abuse during pregnancy and these are outlined in Box 2.^{Reference El Kady, Gilbert, Xing and Smith12,Reference Lewis and Williams13} It cannot be assumed that preverbal infants are unaware and thus unaffected by domestic abuse taking place. There is a 2.5 times increased risk of infant death during pregnancy when domestic abuse occurs, with a common cause of death being blows to the woman's abdomen.^{Reference Meuleners, Lee, Janssen and Fraser14} Domestic abuse during pregnancy is specifically associated with low birth weight and behavioural problems in the child at 42 months of age.^{Reference Hill, Pallitto, McCleary-Sills and Garcia-Moreno15}

Longer-term neurodevelopmental effects on the infant can be explained by the increased levels of cortisol produced by pregnant women enduring the stress of domestic abuse. Increased cortisol levels interrupt the development of the fetus's own neurodevelopmental system. This can manifest in the infant having more difficulty regulating their emotions in childhood.^{Reference Howland, Sandman and Glynn16,Reference Martinez-Torteya, Bogat, Levendosky and von Eye17}

Facilitating a disclosure of domestic abuse

Routine enquiry about domestic abuse is recommended in both perinatal and general mental health settings. Even with routine enquiry, detection of cases falls short of the true prevalence of domestic abuse in people in contact with healthcare services.^{Reference O'Doherty, Hegarty, Ramsay, Davidson, Feder and Taft18} This is partly attributable to barriers perceived or experienced by patients which prevent them from disclosing domestic abuse to healthcare professionals.

A qualitative study^{Reference Rose, Trevillion, Woodall, Morgan, Feder and Howard21} identified fear as a key theme preventing disclosure and these concerns should not be trivialised (Box 3). If disclosure ultimately leads to a decision to leave an abusive relationship, this can expose the victim to a higher risk of lethal violence.^{Reference Fleury, Sullivan and Bybee19} Forty-one per cent of women killed by a partner/former partner in the UK in 2018 had taken steps to separate from them; nearly two-thirds of these women were killed within the first year of separation.²⁰

There are many factors relating to the context of the consultation and skills of the clinician that can also be barriers to disclosure. A victim of domestic abuse may encounter multiple intersectional barriers related to victim-blaming and perceived lack of credibility, as a result of others’ assumptions about gender, ethnicity, sexuality or status as a person with a mental disorder.^{Reference Baillot and Connelly22–Reference Gill and Banga24} People with mental disorders are often seen as less credible.^{Reference Sullivan25} They may have difficulty expressing themselves, anticipate that they may not be believed, or judge that disclosure may increase the risk of abuse or reprisal. It is vital not to automatically assume that a disclosure of domestic abuse is part of a person's mental illness – remember that both domestic abuse and pregnancy can cause deterioration in a person's mental state.

Many pregnant women who experience domestic abuse do not seek professional help.^{Reference Peckover26} There are specific patterns of behaviour and warning signs that can help prompt you to further enquire about domestic abuse during pregnancy (Box 4).

To increase the likelihood that a victim will disclose domestic abuse to you, ensure that a private, face-to-face setting is offered. Although family and carer involvement in healthcare is important, ensure that patients are given the opportunity to speak without a third party present. With the use of virtual appointments increasing following the COVID-19 pandemic, the patient cannot be assumed to be alone and the perpetrator may be able to listen in on the appointment.

A good working knowledge of issues related to domestic abuse will mean that you appear more understanding, credible and trustworthy to a victim. This includes knowledge of patterns of perpetrator behaviour, experiences and dilemmas faced by victims, discrimination and structural barriers to seeking help and awareness of relevant local services. Victims are more likely to disclose domestic abuse if you use open-ended questions to initiate the topic and use sensitive, validating follow-up questions and statements (Box 5). The project Linking Abuse and Recovery through Advocacy for Victims and Perpetrators (LARA-VP) has produced resources that outline multiple methods for exploring domestic abuse within a clinical consultation.^{Reference Yapp, Oram, Lempp, Agnew-Davies, Feder and Trevillion5}

Management following disclosure

One of the most important tests of a therapeutic relationship comes when sensitively handling a disclosure of domestic abuse, as the victim has traversed significant barriers to get to this point. The process involves a delicate balance between working with the victim to make changes to protect themselves and any children and continually reviewing risk.

You first need to be able to assess their immediate safety.²⁷ Useful lines of questioning will establish whether the abuse is ongoing, whether there is anyone else at home, the location of the perpetrator and of any other children, whether there are any active threats and whether the victim has a safe place to stay.

Victims who are at very high risk of serious harm need immediate referral to a multi-agency risk assessment conference (MARAC). In these conferences, representatives from different professional bodies discuss high-risk domestic abuse cases with the desired outcome of an action plan that will safeguard the victims. Pregnancy and giving birth within the past 18 months are MARAC high-risk indicators.²⁹

A more detailed history of the abuse is needed, focusing on the MARAC high-risk indicators (Box 6). Risk assessment tools should not be used purely to generate a risk score, but rather as a means of gathering contextual information for areas of risk that should be enquired about. If cause for concern is identified, you should discuss this with your team and line manager. The SafeLives Domestic Abuse Stalking and Harassment (DASH) checklist is a tool to help identify victims who are at very high risk of harm and therefore need MARAC referral.²⁹

Provide a clear pathway of the next steps and do not rely on the victim to self-refer to other services. Focus on empowering the victim. Immediate action may be needed: a victim who is asking for help should never be discharged to an unsafe environment with the assumption that a referral to social services will be sufficient to protect them. Seek advice and do not act alone. Principles of safe enquiry and locally agreed safeguarding processes should be used to establish the level of risk posed to the victim.³⁰ Risk is dynamic; assess and manage risk on an ongoing basis, and consistently document what has and has not been done.

When a pregnant woman discloses domestic abuse, there are other services and multidisciplinary team members you can seek specific advice from:

• • perinatal mental health services – to assess and manage women with mental illness during the perinatal period; they will play an important role in monitoring the victim's mental state and treatment adherence while continually assessing risk

• • obstetricians and midwives – to help form birth plans for complex pregnancies affected by domestic abuse

• • health visitors

• • social services.

Confidentiality and capacity

Aim to work collaboratively with victims by reassuring them that help is available. Confidentiality should be emphasised, but the limits of this should be made clear. For example, if a vulnerable third party such as a child is at risk, a disclosure to further services may have to be made without consent.³⁰ Be transparent about why you believe information should be shared. Be clear that sharing information with social services will not necessarily mean removal of their child after birth and it is intended as a safeguarding intervention.

Always inform a victim in advance about planned information sharing, unless there is a compelling reason not to do so.³¹ Where you are considering sharing information without consent, you should refer to professional guidance and seek advice from your Caldicott guardian and safeguarding lead. The General Medical Council has issued specific guidance on disclosing information about people who may be at risk of harm.^31,32 Victims should be encouraged to be involved in decisions about disclosing their personal information – if they are declining to do this, try to explore their specific reasons for doing so. Support and empower them to make decisions in their own interests – for example by arranging contact with agencies to support victims of domestic abuse.³¹

A victim's ‘capacity’ to decide to stay in a relationship with a domestic abuse perpetrator, in the context of coercive control and real threats, is a problematic concept. Capacity assessments should never be used as a justification for not helping a victim.^{Reference Beale33} Capacity is a dynamic concept; a victim who initially refuses consent to sharing information with others is not necessarily refusing all forms of help, and may change their mind later on as trust in you develops.

Safeguarding interventions

Where imminent risk to the victim is identified this should be discussed with a local independent domestic violence advocate (IDVA), a local domestic abuse lead or the 24 h National Domestic Abuse Helpline (www.nationaldahelpline.org.uk). IDVAs are specialist domestic abuse professionals who support victims of domestic abuse and will prioritise their safety; they have in-depth knowledge of many areas, including the criminal justice processes and housing, financial and children's services.²⁹ IDVA support is essential in practically helping a victim navigate these complex services as well as the emotional impact of domestic abuse.

As a clinician it is important to be up to date with local referral policies for your area of work. Although there may be a need for the involvement of the police, a victim may have valid reasons for not wanting this, and access to help should never be contingent on reporting to the police.

The interrelating aspects of domestic abuse and mental disorder means that your professional role extends beyond the development of a trusting relationship to facilitate a disclosure and the onward referrals to relevant services. This includes advocacy and the need to address structural discrimination, for example by clearly communicating to other relevant agencies that a victim's disclosure is not symptoms of a mental disorder and therefore must be taken seriously and acted on. Pregnant women are vulnerable to both being victims of domestic abuse and having an increased risk of developing mental disorders and it is your role to highlight this to other agencies.

During the postnatal period, women abruptly lose the wide breadth of services they accessed during pregnancy. Ongoing close liaison with relevant agencies should occur during the postnatal period to effectively safeguard the victim. Longer-term psychiatric treatment planning for the mother and child should also consider the psychological effects of having survived domestic abuse. Specific therapeutic interventions include trauma-focused cognitive–behavioural therapy, eye movement desensitisation and reprocessing and parent–child interventions.

Reflection

As a clinician, be mindful of your own unconscious emotional reactions and countertransference towards patients. Your own personal biases, demographics and beliefs may affect your ability to recognise the warning signs of domestic abuse. Remember to consider domestic abuse in all patients and be especially vigilant in the perinatal period. You should respond sensitively to a disclosure while remaining curious about the patient's story in order to form a safe management plan.

Clinician behaviours remain vital to building a therapeutic relationship and facilitating a disclosure of domestic abuse within hectic clinical environments. Support for clinical issues and reflecting on your emotional response should be available in reflective practice, Balint groups and supervision sessions.

Your colleagues may have been affected by domestic abuse so be sensitive to this when working in multidisciplinary team settings. As clinicians caring for patients within the unique, high-risk perinatal setting, we must also recognise the potential impact of compassion fatigue and secondary trauma on ourselves and our colleagues.