Women's views and experiences of antenatal enquiry for domestic abuse during pregnancy

Abstract

Objective

The aim of this study was to explore the acceptability of antenatal enquiry for domestic abuse from the perspective of women using maternity services. It also sought to understand the experiences of referral and support offered to women who had positively disclosed abuse.

Methods

A multimethod approach was adopted including quantitative and qualitative elements. The survey assessed women's views of the acceptability and impact of routine enquiry for domestic abuse. Interviews aimed, to understand the views and experiences of women who had positively disclosed abuse during their contact with maternity services.

Results

94.4% of those surveyed felt comfortable with a midwife asking about abuse. 96.6% of the participants also believed it was appropriate for a midwife to ask and that midwives should be able to respond to positive disclosure. Interviewees subject to abuse during pregnancy were happy to be questioned, even though they did not always feel able to disclose immediately.

Conclusion

Women had a positive view of antenatal enquiry for domestic abuse in healthcare settings and support its continuation. Women expect to be asked and that midwives can respond appropriately. Raising the issue creates a culture in which women are made aware of the impact of abuse and understand there are avenues of support even if she decides not to leave the relationship. Women may choose not to disclose about the abuse at the initial time of asking, for fear of their own safety but asking signifies that she can disclose about at a later contact.

Introduction

Domestic violence and abuse can include many forms of behaviour including physical, psychological, emotional and sexual, restriction of movements, isolation, deprivation and financial control. More recently, commentators have agreed the term domestic abuse, enables a better understanding of the impact of non‐physical violence.1 It is also considered to encompass cultural concerns such as forced marriage, female genital mutilation and cutting and honour crimes.2

Within the context of the United Kingdom (UK), there were over one million female victims of domestic abuse in England and Wales in the last year. More than 300 000 women were sexually assaulted and 60 000 women were raped.3 The cost of providing public services (including health, legal and social services) to women and families combined with lost economic output of women affected by abuse can amount to billions of pounds. An indicative figure for the minimum cost of dealing with the consequences of abuse against women and girls in the United Kingdom is estimated to be £36.7bn annually.4 However, this does not take into account the long‐term emotional and mental health problems experienced by victims or the fact that many of these crimes go unreported and undetected each year.

Domestic abuse in pregnancy continues to receive increased attention from UK and international policy makers as it can have grave consequences for both the mother and the unborn baby.5, 6, 7, 8, 9 Abuse can lead to recurrent miscarriage, low birth weight, foetal injury, stillbirth and maternal death.10, 11, 12, 13, 14, 15, 16, 17 It is difficult to estimate the exact prevalence of domestic abuse during pregnancy, as it is thought that many women may be reluctant to disclose about the on‐going abuse. Nevertheless, reported prevalence rates of violence in pregnancy range from 0.9 to 20%.18 though more recently, Taillieu and Brownridge19 suggest that the majority of international studies have found prevalence rates of between 3.9 and 8.3%. With Martin et al.20 suggest that a past history of violence and abuse is one of the strongest predictors of pregnancy violence. Between 60 and 96% of women who are abused during their pregnancy were experiencing violence prior to their pregnancy, suggesting that violence during pregnancy is in fact a continuation of pre‐existing violence for the majority of women.19

Health professionals such as general practitioners (GPs), midwives, practice nurses, accident and emergency staff, and health visitors may often be the first point of contact for abused women.20, 21, 22, 23, 24 What is known is that women are more liable to disclose if asked by a caring and knowledgeable professional.25 Healthcare professionals have an important role in identifying women and children who may be experiencing violence and abuse in their personal relationships. However, the continuing unwillingness of health professionals to openly ask a woman about domestic violence has been attributed to a number of reasons including: lack of knowledge and training, time constraints, believing that domestic abuse is a private matter and not the domain of the health service and fear of offending women.21, 26 However, a number of studies have clearly identified that overall the majority of women are in favour of being asked about domestic violence when the question is asked by a caring and knowledgeable professional.24, 26, 27, 28

There is evidence available which suggests women support routine questioning if they are questioned in a sensitive manner, by a well‐trained professional.21, 28, 29 Nonetheless, the debate is on‐going about the best way to identify and support women who are in abusive relationships. There also remains some uncertainty whether routine enquiry for partner violence in health settings is appropriate or indeed effective.29 There have been several systematic reviews that report a lack of robust evidence demonstrating the effectiveness of health services intervention for routine enquiry for domestic violence in terms of improved morbidity or mortality outcomes.30, 31, 32, 33, 34 In contrast, a recent systematic review demonstrated that routine enquiry for domestic abuse is indeed effective, when focused in pregnant populations.35

The aim of this study was to assess the acceptability, experience and consequences of routine antenatal domestic violence enquiry for pregnant women. The study also sought to understand the experiences of referral and support for women who had positively disclosed domestic abuse.

Methods

A multimethod approach was adopted including both quantitative and qualitative elements. A survey aimed to establish the views of women from a wide range of social backgrounds and in‐depth interviews with seven women who had been subject to abuse during pregnancy. The latter provided the opportunity to understand the views and experiences of women who had positively disclosed a history of abuse during their contact with maternity services and identify the reasons why women may opt not to disclose to their care givers. University and NHS Ethical approval was obtained. Close attention was paid to issues of safe guarding, particularly during interviews, in accordance with the Nursing and Midwifery Council (NMC) Code of Professional Conduct36 about the disclosure of information about the risk of harm to children or vulnerable adults. Safety measures were explained, and particular attention was paid to information about child protection and the right to withdraw. National and local support telephone numbers for Women's Aid were included with the survey.

Researchers recognized that these may be highly sensitive interviews; therefore, provision was made for additional support for any issues subsequently women wished to discuss through the participating voluntary organizations. All Interviewees had access to a named support worker from the women's voluntary agencies, and support mechanisms were available post‐interview. The women were also aware that they could invite their support worker to accompany them to the interview; only one participant took up this request. Consistent with the values of the organizations we were working with, all the women received a £10.00 high street voucher as recognition for their time. Pseudonyms were used ensuring participant confidentiality.

Data collection

The survey assessed women's views of the acceptability and impact of routine enquiry for domestic violence on their experiences of maternity care. The survey was developed on the basis of previous work undertaken in the field21, 24, 26, 27, 28 and piloted to ensure data collected was reliable. Amendments were made where piloted questions were considered ambiguous. Biographical data were also collected including ethnicity, age and type of housing. In addition, women were asked to respond to a number of statements using a five‐point Likert scale from strongly agree to strongly disagree. These were connected to the role of the midwife in asking about abuse; appropriateness of being asked and the possible benefits of disclosure. These variables were identified from the qualitative literature and previous work conducted in the field.21, 24, 25, 26, 27, 28 There were also three closed questions establishing whether women had been asked about abuse by their midwife; whether they were experiencing violence in their current relationship; when there was a positive disclosure, women were asked whether they discussed this with the midwife or any other health professional. The survey also included open‐ended questions, women were asked their perception of why midwives ask about violence and any additional views they wanted to express.

One‐to‐one interviews aimed to understand the views and experiences of women who had positively disclosed violence during their contact with maternity services. Biographical information was recorded, women were asked to reflect on their experiences of the maternity services after disclosure, including the degree to which they felt able to respond honestly when asked directly about abuse. Reflections were also sought on how practitioners had shared information with other agencies, and women were asked to include the degree to which the care they received was delivered collaboratively across agencies including suggestions for future service improvement.

The two researchers were involved in conducting the one‐to‐one interviews, which took between 45 min and an hour. All interviews were audio‐recorded and transcribed verbatim with consent. The interviews were mostly conducted at the premises of women's support agencies. One interview was conducted in the woman's home, but at the time of the interview, the woman was separated from her partner. This was still engaged with the women's support services and her named support worker was present during the interview.

Settings and participants

This study took place in a National Health Service Trust in the South West of England. Women were recruited from 12 community clinics, while attending for antenatal care between September 2010 and January 2011. The clinics represented communities with diverse cultural, social and ethnic minority populations with significant numbers of women: from black and ethnic minority populations or living in social and private rented housing. Women were asked by their midwives, if they would like to complete a questionnaire which focused on the acceptability of enquiry for domestic abuse. In total, 300 questionnaires were distributed to unaccompanied women across all participating clinics with a response rate of 79% (236 completed, 64 did not).

Women identified in the survey as having experienced abuse were not recruited for a follow‐up interview for safety reasons. This is because involvement in interviewing could potentially put women at personal risk. It was essential that women who consented to an interview were receiving on‐going support from women's voluntary support agencies and recruitment for the face‐to‐face interviews took place purposively through local voluntary agencies and programmes aimed at supporting women who had experienced domestic violence. A total of seven women agreed to take part although this is a relatively small sample, the challenges facing researchers accessing this ‘hard to reach group’ are well documented.37, 38 This is not least in terms of the time necessary to establish trusting relationships between the researcher, voluntary organizations and women who have suffered abuse. These small numbers do not detract from the in‐depth and insightful nature of the data collected.

Data analysis

Survey data were entered in SPSS version 19 and were independently checked for entry accuracy and data validity including coding for missing values. Response frequencies were tabulated and response percentages were calculated both over all respondents and over sample responses allowing for missing values. 95% confidence intervals for percentages were calculated using SPSS default Clopper–Pearson exact intervals for a binomial proportion. All interviews were transcribed by the researchers conducting the interviews, imported to specialist software package NVivo 8 and double coded, with no substantial differences highlighted. Informed by grounded theory and using the method of constant comparative analysis, it was possible to move back and forth between conceptual speculation identified within the literature, data collection and analysis and personal reflection.39 The sample size enabled interview transcripts to be analysed using a traditional ‘cut‐and‐paste’ approach, whereby the researcher reads and re‐reads the transcripts drawing out themes and subthemes. This process illuminated three over arching themes: types of abuse experienced during pregnancy; views of enquiry about domestic abuse and experiences of maternity services, perceptions of trust and the matter of keeping silent about the abuse. The primary purpose of the interviews was to ascertain the women's views and thoughts around the role of the midwife in routine antenatal enquiry. It was evident that some of the women wanted to talk to the researchers about some of the abusive behaviours they had experienced during pregnancy.

Findings

Profile of survey respondents

The majority of the women who completed the questionnaire were white British (79.1%) but also included a significant number of women from a number of ethnic and cultural groups, demonstrated in Table 1. Although the survey was translated into Polish and Somali, all those who responded completed in English.

Table 1.

Ethnicity of sample

	Frequency	Percentage	Valid percentage
White British	186	78.8	79.1
White Other	20	8.5	8.5
Black (British, African, Caribbean)	12	5.1	5.1
Asian (British, Bangladesh, Indian, Pakistani)	8	3.4	3.4
Other	2	0.8	0.9
Mixed ethnicity	7	3.0	3.0
Total	235	99.6	100.0
Missing Data	1	0.4

Women lived in a range of circumstances, with approximately 59.0% of the pregnant women living in privately owned accommodations, 41.1% were tenants, living with friends, in temporary accommodation or other (Table 2).

Table 2.

Housing type of sample

	Frequency	Percentage	Valid percentage
Private owned	135	57.2	59.0
Private rented	55	23.3	24.0
Council	22	9.3	9.6
Temporary accommodation	5	2.1	2.1
Friends	2	0.8	0.9
Others	10	4.2	4.4
Total	229	97.0	100.0
Missing data	7	3.0

Table 3 depicts at what stage of their pregnancy the women were asked by a midwife about domestic abuse. The table indicates that a large proportion of the women (48.7%) were asked by a midwife between the weeks of 8 to 16 weeks gestation, with a large percentage of women, (30.9%) being asked at the booking visit.

Table 3.

Stage of pregnancy when women were asked by the midwife about domestic violence

Stage asked (weeks)	Frequency	Percentage	Sample percentage
4–8	43	18.2	23.8
9–12	70	29.7	38.7
13–16	12	5.1	6.6
17–20	4	1.7	2.2
21–33	0	0.0	0.0
34–38	4	1.7	2.2
Did not ask	48	20.3	26.5
Total	181	76.7	100
Missing	55	23.3

Levels of enquiry, disclosure and women's perceptions of being asked

Women were asked to respond whether a midwife had asked about domestic abuse during their pregnancy: 79.0% (95% confidence interval ranges from 73.17 to 84.02%) of the respondents reported that they had been asked about domestic violence during their pregnancy with 21.0% reporting that they had not been asked. Response from the survey data signified that four of the 236 respondents were experiencing domestic abuse during their current pregnancy. Of the four women who were experiencing domestic abuse, only two had discussed the violence with the midwife.

In addition, an open‐ended question, asked the women to explain the reasons why they felt midwives asked about domestic violence, a total of 230 women responded to this question. Some of the reasons women gave were linked to protection of the mother or child (13%); concerns over safety (25%); concerns over the health of the mother and baby (22%). Women identified these concerns as concerns relating to miscarriage, stress, depression and harm to the baby. Nineteen of the women who gave this answer made a direct link between domestic violence and pregnancy, suggesting that domestic violence started in pregnancy, intensified or pregnancy in itself made women more vulnerable to violence. 11% stated that the reason for asking was so that help and support could be provided for women who were at risk.

A dominant concern about asking about violence is that women may be fearful of disclosing abuse because of the potential involvement of child protection services. Twenty‐five (11%) of all responses made reference to the monitoring aspects of midwives enquiring and 2% highlighted that domestic violence was a crime and should be treated as such. Respondents felt it was important midwives offered women an opportunity to talk about subjects or concerns that they would not normally share without being prompted (6%). This characterized the possibility of prevention of and referral to appropriate agencies and in some instances, an end to women's victimization (10%).

Acceptability of routine enquiry

To establish the degree to which women have found enquiry acceptable, a set of statements were developed. Each question was on a five‐point Likert scale from strongly agree to strongly disagree, which women were asked to respond to. The results are summarized in Table 4.

Table 4.

Percentage responses to acceptability of routine enquiry

How much do you agree with the following statements?	Strongly agree %	Agree (%)	Neither (%)	Disagree (%)	Strongly	Non‐response (%)
I feel comfortable with a midwife asking about domestic violence	50	44	4	1	1	0
I understand the reasons why the midwife asks about domestic violence	60	34	4	1	0	1
I do not think it is the role of the midwife to ask about domestic violence	1	2	8	38	50	1
I think domestic violence is too sensitive and embarrassing to discuss with the midwife	0	3	9	45	42	1
I think that women who are experiencing domestic violence would benefit from telling the midwife	48	43	5	3	1	0
I think midwives should be able to offer advice and support to a woman experiencing domestic violence	58	37	2	2	1	0
I think it is appropriate for a midwife to ask about domestic violence	57	39	3	0	0	1

Significantly, the key findings in the table above demonstrate that 94.4% of the women felt comfortable with a midwife asking about domestic violence (95% confidence interval ranges from 90.69 to 97.01%). 96.6% also considered it is appropriate for a midwife to ask about domestic abuse [95% confidence interval (93.38%; 98.51%)]. 95.3% also understood the reasons why the midwife should ask about domestic violence (95% confidence interval for this percentage ranges from 91.71 to 97.62%).

Interviews with survivors of domestic abuse

Domestic abuse, pregnancy and the experience of using maternity services

The purpose of the interviews with service users who were known to have experienced abuse was to qualitatively explore their experiences of maternity services, and their views of routine antenatal enquiry. The women's support agency provides specialist domestic abuse services to women and children including a dedicated Black, Minority Ethnic, South Asian and Somali service. Other services include safe houses, children's services, resettlement and crisis intervention. The freedom programme is a 12‐week programme that provides information and understanding for women who currently are or have previously experienced domestic violence and abuse. Seven interviews were conducted with women who all had experience of the local maternity services.

Profile of interview participants

The ages of the seven women interviewed ranged from 24 to 38 years. All the women had accessed the maternity services at the Trust. Women's ethnic backgrounds were as follows: White British, Black British and European. All the women had children. One woman was still with her abusive partner. The remaining six had separated from their partner. Two of the women were pregnant at the time of the interviews. Four of the participants were not in paid employment. Biographical information is summarized in the Table 5 below:

Table 5.

Participant biographical information

Name	Age	Ethnicity	Occupational status	Children	Status of living arrangements
Amelia	28	Black European	Hairdresser	1 child (4 months)	Separated from partner
Wendy	38	White British	Personal assistant	1 child (4 years)	Separated from partner
Nancy	34	White British	Full‐time mother	1 child (2 years)	Separated from partner
Theresa	33	White British	Full‐time mother	3 children (9, 5 years and 23 months)	Separated from partner
Debbie	24	White British	Full‐time mother	2 children (7, 4 years and 32 weeks pregnant)	Separated from partner
Nasreen	32	Asian British	Computer Programmer	2 children (11 years, 22 months and 12 weeks pregnant)	Still living with partner
Lousie	24	White British	Full‐time mother	1 child (20 months)	Separated from partner

Experiences of abuse during pregnancy

The women reported a range of abusive behaviours, including emotional, controlling and physical violence. All those interviewed reported being bombarded with verbal and frightening abuse: this caused them to be fearful of their partner's behaviour, even if they were not physically abusive. This fear is eloquently described by Theresa:

most nights you feel like you are just living on edge you don't know what mood he is going to come home in and then you are just fearful of what mood he is going to come home in. I don't know just living in fear actually and I think I prepared myself sometimes as well for it to happen. So I was ready for it to happen (Theresa).

Such findings support previous research in the field, which has suggested that women experiencing abuse pre pregnancy encountered an escalation in psychological and sexually abusive behaviours during pregnancy.20, 40 Two of the participants in this particular study did not experience any form of physical violence during their pregnancy, although they were subjected to extreme verbal abuse and physical threats. One participant attributed the start of abusive behaviour by her partner to an unplanned pregnancy. Amelia had not experienced any form of abuse in the relationship previously; however, during the pregnancy, her partner became extremely abusive and aggressive towards her, with threats to kill her and the unborn baby if she did not agree to a termination of pregnancy.

Evidence suggests that an unwanted pregnancy by a male partner may trigger abuse in a relationship.26 Indeed, Stewart and Cecutti41 reported that women with an unplanned pregnancy were almost three times more likely to experience violence compared with women with a planned pregnancy. One explanation for initiation of violence by men at this time is that a pregnancy may appear threatening to a partner who needs to keep tight control and the most reported reasons for the initiation of abuse can be an unwanted pregnancy and financial hardship.14, 42 Amelia who had been brought to the UK from Portugal by her boyfriend four years earlier felt that her vulnerability was heightened because English was not her first language. Non‐English speaking women have been identified as being at particular risk to abuse within the last two Confidential Enquiries, due to isolation and inability to access help.2, 43

For some of the participants, the controlling behaviour during the pregnancy by their partner was difficult to come to terms with:

He was not really physically violent during pregnancy, he occasionally pushed or shoved me out the way, but he became more controlling, he would tell me what to wear, I was usually only allowed to wear jogging bottoms. I was not allowed to dye my hair and he wanted me to stay in the house all the time, he did not like me going out to meet my family or friends (Debbie).

Women's views on antenatal enquiry

All the participants' interviewed believed that it was acceptable for midwives to ask about domestic abuse. It was also clear that the participants understood why midwives asked pregnant women about abuse. One participant reported that she had not been asked about domestic abuse during her first two pregnancies. However, at the time of this interview, she was currently 32 weeks pregnant and had been asked about abuse by her current midwife. Debbie acknowledged she would have disclosed about the abuse in her previous pregnancies had she had been asked:

I would have disclosed to a midwife if they had asked, but they did not ask in my first two pregnancies, although I think initially I was not aware that what I was experiencing was domestic violence as it was just psychological and controlling behaviour. It took me a few years to realize that what I was experiencing was domestic violence, yeah how stupid was I? (Debbie).

While women spoke assertively about the midwives role in asking, there was no guarantee this would result in a positive disclosure, however, it did appear to set a context in which women felt able to talk about abuse, if not then at a later date.

Disclosing abuse to professionals

Women were often cautious about opening up to the midwife during pregnancy and sometimes concealed on‐going abuse. Reasons for this are complex, but appeared to be associated with a number of conflicting feelings; women recognized the behaviour of their partner was wrong, but hoped he would change, and in some instances, women saw themselves as part of the problem. This resulted in anxiety about not being believed, embarrassment and fear of the consequences of disclosure. One participant reported that she was fearful of Social Services finding out about the abuse:

I did not tell the midwife, not because I did not want too, but because of social services, I did not want her to tell social services. Most people are scared of social services, especially if they have got kids. In a domestic relationship most people don't like social services so they will just suffer because they don't want social services involved (Theresa).

Others felt comfortable enough to disclose about the violence in the relationship. Amelia was very positive about the help the midwife had given her through the pregnancy, acknowledging how much support the midwives had provided:

I was able to trust them enough to tell them. I was not embarrassed by being asked. I know they ask because they care…Yes the midwife was so helpful, as soon as I told her about the violence and threats she helped me, even helping me fill out the necessary forms. She came to visit me in the refuge when I was no longer staying at my friend's house. She even arranged for the interpreter to be there for my scan appointment. I felt I could trust her (Amelia).

Some of the women who were experiencing abuse during pregnancy deliberated about how they felt when they had not been asked. They felt it was important that the midwife ask the question, as they themselves found it difficult to broach the subject:

Sometimes I thought that if only I had the chance to talk to her, it would have been nice just to have a talk with someone. I didn't expect her to take action or for it to go any further with the information. I just need somebody to talk too, really because at that time I was still trying to keep my marriage going for the sake of my baby (Wendy).

Controlling behaviour is a recognized feature of domestic abuse and has a significant impact on women's ability to access maternity services, in particular having time alone with the midwife. Often abusive partners will attend all appointments in an attempt to control women's ability to expose the abuse or ask for help. However, when women were able to disclose, they highlighted how supportive the midwife had been.

Discussion and conclusion

This research does have limitations; not least the survey was conducted in one NHS Trust and therefore raises questions about generalizability. Nevertheless, researchers were able to ensure that the survey was distributed across a range of socio‐economic populations, so if replicated similar findings would be likely to be found. This survey although one of the largest conducted in the UK focused on domestic abuse enquiry in maternity care,44, 45, 46, 47 it did not include women who were accompanied by a partner or family member for safety reasons. In addition, the qualitative interviewing included small numbers of women who were in the main no longer living in abusive relationships and therefore does not address the experiences of women who remain in abusive relationships without support.

Limitations acknowledged, the findings are consistent with other work in the field,21, 24, 27, 28, 47 the majority of women surveyed in this study not only felt comfortable about being asked about domestic abuse, but thought it was appropriate and essential that midwives should ask. Moreover, women understood a wide range of complex reasons for why it was necessary to enquire, strongly articulating links between pregnancy and the specific implications of abuse during this time. The women also articulated the associations between women's mental health and the implications for children of living with abuse. This may be due to the coverage of domestic violence on popular television dramas, awareness raising campaigns and the national adoption of antenatal enquiry within midwifery services.

Women in this study not only expected midwives to ask them about domestic abuse, they also believed they should be trained to provide support and advice to women who positively disclosed. While there has been preliminary work suggesting women's vulnerability to abuse during pregnancy,17, 18, 19, 20 little work to date has considered women's first‐hand accounts of the nature of the abuse. The accounts highlighted that for some women abuse started in pregnancy, verbal or physical threats increased or controlling behaviours intensified. Women also talked about the fear this engendered for both themselves and their unborn baby, recent research suggests pregnancy itself can be risk factor for violence.48 Pregnancy can emphasize a woman's reliance on an abusive relationship and exacerbate feelings of vulnerability and lack of control.26, 42, 49 The findings from this study support the findings from Bacchus et al.21, 46 that women can find routine enquiry during pregnancy beneficial even if they chose not to disclose about the violence in the relationship, as it removes any feelings of shame and isolation that a woman may feel. It also provides women with a mechanism for disclosure and referral to relevant support agencies at a later date, should the violence intensify during pregnancy.

The women themselves believed that antenatal enquiry was important. However, their anxieties appeared to be concerned with feelings of embarrassment, fear of the partner finding out and the potential risk of an automatic referral to Children's Services. Despite such concerns, women felt it was important that midwives continued to ask women about domestic abuse as they felt it was too difficult for them to raise the issue themselves.

Midwives raising the subject may be enough to raise women's awareness, signifying opportunities to disclose at a later date. The findings from the interviews suggest that the most helpful way to enquire about domestic abuse is for clinicians to assume a non‐judgemental positive approach to questioning. Women may find it difficult to bring up the topic of domestic abuse; therefore, direct questioning is needed to make sure that women are afforded the opportunity to access support and help.

Conclusions

This work suggests that women have a positive view of enquiry by midwives and supports the continuation of routine antenatal enquiry for domestic violence during pregnancy. Women expect to be asked and believe their midwives should be able to respond appropriately. Midwives need to be cognisant of women's fear of disclosing, in terms of the implications for both the women's health and well‐being and her genuine anxiety of child protection concerns. Raising the issue creates a culture in which women are made aware of the impact of abuse and understand there are avenues of support, and support mechanisms in place that women can access, even if they elect to stay in the relationship. Women who had experienced abuse reported that even when asked directly they may elect not to disclose at the initial time of asking, however, routine provided them with opportunities for disclosure and referral to relevant support agencies at a later date, particularly if the abuse intensified during pregnancy.

Acknowledgements

Thanks to the midwives and maternity service users who gave up their time to participate in the study. This study was funded by the Avon Primary Care Research Collaborative.

Conflict of interest

No conflict of interests.