[CG] Identifying and responding to domestic abuse in Obstetric & Gynaecology settings

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Objectives

Other relevant policies:

Gender Based Violence Policy, Policy on Stalking, Health and Safety Policy, Forced Marriage Policy, Adult Support and Protection guidance and Procedures, Child Protection Procedures, Mental Health and wellbeing policy, Alcohol and Substance Misuse, Human Trafficking, Interpreting Policy.

Please report any inaccuracies or issues with this guideline using our online form

NHS Greater Glasgow & Clyde (NHSGG&C) recognises gender-based violence (GBV) as both a cause and consequence of gender inequality and acknowledges the evidence that it is overwhelmingly perpetrated by men against women and children, with the latter more at risk from men they know. As part of its Equality Scheme, NHSGG&C has produced several gender based violence action plans which identify domestic abuse as part of a wider continuum of abuse, which also includes child sexual abuse, rape & sexual assault, sexual harassment, female genital mutilation, forced marriage and commercial sexual exploitation.

GBV cuts across all boundaries of class, ethnicity, religion and age. At the same time women in marginalised groups can suffer discrimination in relation to ethnicity, (dis)ability, sexual orientation, poverty, migrant or refugee status which can increase and intensify their vulnerability to abuse and limit access to services. Given the health consequences and links with child protection NHS staff have a pivotal role in responding to this issue.

The Scottish Government defines domestic abuse as;

“perpetrated by partners or ex partners (which) can include physical abuse (assault and physical attack involving a range of behaviour), sexual abuse (acts which degrade and humiliate women & are perpetrated against their will, including rape) and mental and emotional abuse (such as threats, verbal abuse, racial abuse, withholding money and other types of controlling behaviour such as isolation from family and friends)

The purpose of this guidance is to assist staff (W&CD) in identifying and responding sensitively to women accessing services during their reproductive years, who may have current or past experience of domestic abuse. This applies to areas where routine enquiry of domestic abuse has been implemented and for all other areas within Obstetrics & Gynaecology.

Routine enquiry

  • Be aware of the indicators of domestic abuse & its impact on health & (Appendix 1) & www.gbv.scot.nhs.uk  
  • See all women alone for part of the consultation to ensure that any sensitive information can be discussed safely & in confidence.
  • Always set the context prior to asking about abuse. (Appendix 2)
  • Follow this up with a direct question that requires a direct answer (Appendix 2)
  • Always discuss confidentiality & its limits (child protection and vulnerable adults).    
  • Follow NHSGGC Spoken Language, British Sign Language and Communication Support Interpreting Policy (2012). It is not appropriate to use  family or friends to communicate except in an emergency situation.

Have information on support services available in the department in places where they can be picked up easily

Asking about abuse at other times

Examples of what to ask:

  • “I notice you have cuts/bruises…has someone hurt you?
  • Some of our patients who have these symptoms are living with an abusive partner…is that something that affects you?

Asking about domestic abuse will not always result in disclosure. Some women may choose to disclose at a later date & others will never access support.

Responding to Disclosure

The safety of the woman and any children is paramount and therefore it is crucial that health workers assess any immediate risk/safety issues following disclosure and follow child protection and vulnerable adult procedures where there are any concerns.

Key aspects to explore when assessing risk: 

  • How frequent and severe is the abuse?
  • Is she afraid for herself or her children?
  • Is she isolated and without support?
  • Is she being harassed or stalked?
  • Is there sexual violence, pressure or jealousy?
  • Are there any other risk factors such as drug, alcohol or mental health issues?

For many women leaving is the most dangerous point in the relationship, & any fears raised by the woman for her safety should be taken seriously. Women seldom exaggerate the risk of harm & are more likely to minimise the abuse.

Safety Planning

Following disclosure the health worker should explore options with the woman to help her focus on her current and future safety.

  • Help her identify a safe place she can go with her children i.e. friends, family, refuge or temporary accommodation
  • Discuss packing a bag with essential documents, clothes, money, medication, important phone numbers in case she needs to leave in a hurry. Store the bag safely where the perpetrator won’t find it
  • Offer her the Scottish Domestic abuse & Forced Marriage Helpline Number 0800 027 1234 –and  the opportunity to phone the helpline from a private room
  • Does she want to report the incident to the police? Advise her to dial 999 in an emergency or 101 at other times
  • Follow child protection and vulnerable adult procedures where there are any concerns.
  • Ensure a follow-up appointment is arranged where appropriate.

Risk assessment is not a one off event and risk may change over time; therefore ongoing risk assessment is required.

 

Documentation of Abuse

This is important health information which should be documented in the woman’s hospital notes, never in ‘hand-held’ records.  .

Document any disclosure using the woman’s own words and include any action or referrals and plans for follow up.

Resources

Scottish Domestic Abuse & Forced Marriage 24 hour helpline
0800 027 1234 www.sdah.org.uk– men women and children

For support and information on domestic abuse: 
www.scottishwomensaid.org.uk

Help and information for anyone who has been raped or sexually abused: 
www.rapecrisisscotland.org.uk

Website for perpetrators of domestic abuse looking for help to address their behaviour:
www.respect.uk.net

Support for male victims of domestic abuse: 
www.mensadviceline.org.uk

Advice and information for lesbian, gay, bisexual and transgender people experiencing domestic abuse:
www.lgbtdomesticabuse.org.uk
www.brokenrainbow.org.uk/help/helpline   

Police Scotland Information and support for victims of domestic abuse: 
http://www.scotland.police.uk/keep-safe/advice-for-victims-of-crime/domesticabuse/reporting-domestic-abuse/

For further information on GBV
www.equality.scot.nhs.uk

A series of guides to support health workers on gender based violence is available at:
www.gbv.scot.nhs.uk

Support for Staff

Support for Staff can be obtained via:

  • Your line manager or Supervisor of Midwives
  • Employee Policy on Domestic Abuse - Staffnet HR policies
  • Occupational Health and employee counselling service
  • The Pastoral Care Team can provide/access religious, spiritual and emotional support.

For professional or personal support regarding Gender Based Violence contact the GBV Resource Unit 0141 201 9777 or e-mail: gbvunit@ggc.scot.nhs.uk  or visit our website on Staffnet.

Appendix 1

Impact on Health 

Physical

  • Cuts / bruises Fractures /sprains. Injuries to the head, neck, chest, breasts & abdomen Repeated or chronic injuries Loss of hearing / vision
  • Chronic pain, ill health
  • Dental problems

Mental /Emotional

  • Depression/anxiety
  • Panic attacks
  • Somatic complaints
  • Eating disorders Post-traumatic stress disorder Alcohol / drug use Self-harm
  • Suicidal ideation
  • Attempted suicide

Sexual/Reproductive

  • Higher incidence of miscarriage and placental abruption Uterine infection
  • Unwanted pregnancy
  • Chronic pelvic pain Recurrent urinary tract infections
  • Rape and sexual assault
  • Gynaecological problems

Children’s Health

  • Pre-term birth
  • Low birth weight
  • Failure to thrive
  • Bedwetting
  • Anxiety / depression
  • Withdrawn
  • Behavioural problems
  • Self harm
  • Physical injuries

 

Possible Indicators of Abuse

  • Missed appointments and non-compliance with treatment
  • Frequent presentations to health settings or delay in seeking medical treatment/advice
  • Overbearing or overly solicitous partner who is always present
  • Denial or minimising of abuse
  • Injuries at different stages of healing or that don’t fit with the explanation given
  • Appears evasive, socially withdrawn and is hesitant
  • Children on the child protection register or referred to other specialists for behavioural/emotional or developmental problems

These lists are not exhaustive & there may be other causes.

Some women experiencing abuse may show no signs or indicators.

Appendix 2

Routine Enquiry

Setting the Context:

 “Around 1:4 women experience emotional, sexual or physical abuse, because we know this affects your health (and pregnancy), we now routinely ask all women……”

Follow setting the context by giving a short explanation of each of the forms of abuse e.g. physical abuse can be a push, slap or kick, emotional abuse may be your partner putting you down or not letting you see family or friends and sexual abuse could be your partner forcing you to do something you don’t want to.

Examples of Direct Questions: 

  • Have you ever felt afraid of a partner/ex or family member?
  • Has your partner/ex, ever physically hurt or threatened you or your children?
  • Has your partner/ex ever destroyed things that you cared about?
  • Has your partner/ex ever forced you to have sex when you didn’t want to?
  • Does he/she force you to engage in sex that makes you feel uncomfortable?
  • Does your partner/ex ever get jealous? If so, how does he act?
  • Does your partner/ex try to control you in any way, for example preventing you from going out or limiting contact with your family or friends?

These questions are intended as prompts, it is not necessary to ask all of them and they should not be used as a checklist.

Last reviewed: 01 June 2016

Next review: 30 June 2021

Author(s): Claire Rowan

Co-Author(s): Lorna Pender & Linda McGurk, Gender Based Violence Advisors

Approved By: Obstetric Guideline Group