The Women’s Safety Summit – Needs to include pregnancy

The effects on women and their children of violence during pregnancy cannot be overstated.  It is associated with several types of harm, both to a pregnant mother and to her unborn baby.

We at Maternal Health Matters Inc. would like the National Federation Reform Council Taskforce on Women’s Safety to ensure that the following key considerations are incorporated in the next National Plan:  

• Address the experiences of pregnant women and their children across all approaches, including prevention, early intervention, intervention, response and recovery

• Further, address pregnant women’s and children’s experiences across all relevant focus areas through responsive, targeted and meaningful approaches (including culturally responsive interventions with men and maternity care professionals who use violence)  that are tailored to the diversity of pregnant women.

• Children’s experiences of violence should be recognised and responded to in their own right in a culturally responsive way and acknowledging the rights of both mothers and children.

• Considerations of care pathways, pre-pregnancy trauma and experiences of violence, language barriers, prejudice, racism, culture, religious affiliation, community beliefs and influences, disability and age are intersectional disadvantages particularly critical in this regard and enable a more nuanced understanding of gendered power imbalances and how systemic responses can be enhanced to empower and protect pregnant women

Background 

The effects on women and their children of violence during pregnancy cannot be overstated.  It is associated with several types of harm, both to a pregnant mother and to her unborn baby.

There are three elements to the violence pregnant women experience and both need to be addressed.

1. Intimate partner and family violence,
2. Health Professional Obstetric violence, and
3. Institutional structural violence within the health system.

There are three-hundred-thousand plus births annually across Australia, therefore, pregnancy and birth is a critical touchstone between our health and welfare systems and the great diversity of families.

We know that 25% of pregnant women experience their first occasion of intimate partner violence during the antenatal period.

Health professionals are not immune from being abusive and coercive as health systems often reflect the deeper dynamics of power and inequity that shape the broader societies in which they are embedded.

Disrespectful maternity care represents a dimension of violence against women and remains a significant public health issue, with an ever increasing number of women emerging from pregnancy and birth feeling traumatised as a consequence of the disrespect, abuse and the violence they encounter.  This abuse, can vary from verbal insults to a refusal of information, authoritarian behaviour, such as forced immobilisation, forced monitoring, an unwanted vaginal examination or episiotomy, or a refusal of pain relief – that is any act that forces the pregnant woman to undergo something against her will or which strips her of her dignity, including the problem of obstetric violence that arises in the context of over-medicalising birth & coercive control.

Violence in pregnancy, contributes to poorer health outcomes as well as a spectrum of psychological trauma. One-third or more of Australian women describe their births as traumatic and as many as one-third of that number develop childbirth-related post-traumatic stress disorder. Obstetric violence can be especially traumatizing for family violence and sexual assault survivors.

Research has shown that children exposed to violence can experience long-term effects on their development and have increased risk of mental health issues, and behavioural and learning difficulties.

Prevention  

All investment into primary prevention must include a long-term targeted focus on preventing violence against pregnant women through evidence based, whole-of-community approach, including working with men and boys.

This includes:

• funding for health education in schools re human rights and respectful care;
• pre-pregnancy and early pregnancy support programs so women understand their rights and their options to achieve respectful maternity care during pregnancy;
• providing transition to parenting programs during pregnancy that prepare both men and women for the joys and challenges of parenting and maintaining personal safety;
• expanded postnatal support services up to twelve months after the birth so as to recognise and respond to the transition to parenthood stresses that have the potential to impact on personal safety, and
• education of maternity care professionals on human rights and respectful maternity care.

 Community-led prevention initiatives should be prioritised.   

Community-led primary prevention in maternity contexts should be coordinated nationally through a community-of-practice approach to facilitate the sharing of specialist knowledge and resources, while aligning with and informing national primary prevention frameworks and approaches.

Primary prevention should be led by representative maternity consumer bodies in collaboration with health professional and relationship organisations with specialist primary prevention expertise.

Early intervention  

All pregnant women are vulnerable during pregnancy to intimate partner violence and maternity professional abuse and disrespect.  They require access to equitable supports and services; including immediate access to continuity of midwifery care as it promotes human rights and safe maternity services, universal income support, emergency housing, and health care – crucial to achieving safety, economic, and social recovery.

Practitioners of maternity care and all service touchpoints with potential interaction with pregnant should be supported with knowledge and skills in cultural responsiveness and in dealing with disclosures of violence through safe referrals and a multi-agency approach.

Measures must be taken to address structural/systemic barriers to access arising from the intersection of health and social security regulations that prevents a significant proportion of pregnant women from seeking safety and recovery.

Equally measures must be taken to address structural/systemic barriers to respectful maternity care arising from the intersection of a women’s’ human rights; funding models, and health professional regulations and patriarchy, that prevents a significant proportion of women from seeking safety and recovery.

The government strategy – Woman-centred care: Strategic directions for Australian maternity services would ensure that all women receive respectful maternity care; however, it is yet to be implemented. We call for the strategy to be funded, implemented and evaluated.

Response 

 Investment towards strengthening service systems to better respond to the needs and circumstances of pregnant women must provide a focus both on the cultural and the structural/systemic barriers to access.

The needs and experiences of pregnant women should be considered across all relevant areas of focus—including controlling behaviours, coercive control, trauma, financial abuse, technology-facilitated abuse, and perpetrator interventions—and must be  reflected in the next National Plan development and implementation.

It is critical to recognise the diversity of pregnant women’s experiences, that family members perpetuate domestic violence, and that there may be multiple perpetrators. Such recognition has significant implications for service responses, as well as justice and policing responses.

Furthermore, it is critical to recognise that health professional can perpetrate violence when providing care and that there may be multiple perpetrators. Such recognition has significant implications for health service responses, as well as justice and policing responses.

Research, data collection and monitoring

Critically, the equitable and inclusive impact of the next National Plan must be underpinned  by a robust data collection and monitoring framework, including reports by women on outcomes of care and their experience of violence during pregnancy, both in the home and when receiving maternity care.

If we are to reduce intergenerational trauma the research must enable nuanced analysis based on the experiences of trauma and violence, language barriers, prejudice, culture, racism, religious affiliation, disability and age to inform policy and practice that is truly responsive to the experiences and needs of pregnant women and their children.

In making this statement, we draw on the following evidence:  

 Australian Institute of Health and Welfare 2018. Family, domestic and sexual violence in Australia 2018. Cat. no. FDV 2. Canberra: AIHW. https://www.aihw.gov.au/getmedia/d1a8d479-a39a-48c1-bbe2-4b27c7a321e0/aihw-fdv-02.pdf.aspx?inline=true

Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK & Souza JP (2015) “The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed- Methods Systematic Review” 12(6) PLoS Med – Available here: http://bit.ly/1NwjhA7.

Byrom, Sheena, 2015, United Nations – http://www.slideshare.net/SheenaByrom/the-roar-behind-the-silence-may-2015 

Campo, Monica (2015), Domestic and family violence in pregnancy and early parenthood

Overview and emerging interventions, Australian Government.

https://aifs.gov.au/cfca/publications/domestic-and-family-violence-pregnancy-and-early-parenthood

 Christine H. Morton PhD, Penny Simkin PT First published: (2019) Can respectful maternity care save and improve lives? https://doi.org/10.1111/birt.12444

CLAHRC South London (2016), Relationships: the pathway to safe, high-quality maternity care. Available at: <http://www.clahrc-southlondon.nihr.ac.uk/maternity-and-womens-health>

NHS National Institute Health Research, “Access to continuity of midwife care should be expanded, says new report” (13 April 2016) Available at: CLAHRC South London | Access to continuity of midwife care should be expanded, says new report (nihr.ac.uk)

Dahlen, Hannah; 2015; “But Your Child Might Die” The Right To Defy Doctor’s Orders; The Ethics Centre; http://www.ethics.org.au/on-ethics/our-articles/april-2015-(1)/part-two-%E2%80%98but-your-child-might-die%E2%80%99-the-right-to-d#.VSYItpVVGog.twitter 

 Dahlen Hannah, Bashi Kumar-Hazard, Virginia Schmied; (2020); Birthing Outside the System

The Canary in the Coal Mine; Routledge ISBN 9781138592704; https://www.routledge.com/Birthing-Outside-the-System-The-Canary-in-the-Coal-Mine/Dahlen-Kumar-Hazard-Schmied/p/book/9780367506605

Dahlen HG, Munoz AM, Schmied V, et al; The relationship between intimate partner violence reported at the first antenatal booking visit and obstetric and perinatal outcomes in an ethnically diverse group of Australian pregnant women: a population-based study over 10 years BMJ Open 2018;8:e019566. doi: 10.1136/bmjopen-2017-019566, https://bmjopen.bmj.com/content/8/4/e019566

D’Gregorio P, (2010) “Obstetric violence: a new legal term introduced in Venezuela” 111(3) Int J Gynaecol Obstet 201-2. 9

Figo Guidelines; 2015; Mother−baby friendly birthing facilities; International Journal of Gynecology and Obstetrics; 128 (2015) 95–99; (http://whiteribbonalliance.org/wp-content/uploads/2015/03/MBFBF-guidelines.pdf and the Global White Ribbon Alliance for Safe Motherhood guidelines.)

 Freedman LP, Kruk M (2014) Disrespect and abuse of women in childbirth: challenging the global quality and accountability agendas. PLoS Med. 2015 Jun; 12(6): e1001849. https://www.ncbi.nlm.nih.gov/pubmed/24965825 

 Jewkes R & Penn-Kekana L (2015) “Mistreatment of Women in Childbirth: Time for Action on This Important Dimension of Violence against Women” 12(6) PLoS Med e1001849. Available here: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001847

 Keedle, H; Virginia Schmied, Elaine Burns and Hannah G Dahlen; 2015; Women’s reasons for, and experiences of, choosing a homebirth following a caesarean section; BMC Pregnancy and Childbirth; 15:206; DOI: 10.1186/s12884-015-0639-4; http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-015-0639-4 

 Miller PhD, Prof Suellen; Edgardo Abalos, MD; Monica Chamillard, MD; Agustin Ciapponi, Msc; Daniela Colaci, MD; Daniel Comandé, BIS; et al. (2016) Beyond too little, too late and too much, too soon: A pathway towards evidence-based, respectful maternity care worldwide; The Lancet. DOI:https://doi.org/10.1016/S0140-6736(16)31472-6

 Miltenburg, Andrea; Fleur Lambermon, Cees Hamelink and Tarek Meguid; 2016; Maternity care and Human Rights: what do women think?; BMC International Health and Human Rights; BMC series – open, inclusive and trusted201616:17; DOI: 10.1186/s12914-016-0091-1; https://bmcinthealthhumrights.biomedcentral.com/articles/10.1186/s12914-016-0091-1.

Rachel Reed , Rachael Sharman & Christian Inglis; (2017); Women’s descriptions of childbirth trauma relating to care provider actions and interactions BMC Pregnancy and Childbirth 17, Article number: 21

Rayment-Jones H, Murrells T, & Sandall J (2015) “An investigation of the relationship between the caseload model of midwifery for socially disadvantaged women and childbirth outcomes using routine data – A retrospective study” 31(4) Midwifery 409-17.

Sandall J, Soltani H, Gates S, Shennan A, Devane D; (20); Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting; http://www.cochrane.org/CD004667/PREG_midwife-led-continuity-models-care-compared-other-models-care-women-during-pregnancy-birth-and-early)

Shakibazadeh E, M Namadian, MA Bohren, JP Vogel, A Rashidian, V Nogueira Pileggi, S Madeira, S Leathersich, Ӧ Tunçalp, OT Oladapo, JP Souza, AM Gülmezoglu; (2017); Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis; BJOG, https://doi.org/10.1111/1471-0528.15015

Stephan Oelhafen, Manuel Trachsel, Settimio Monteverde, Luigi Raio and Eva Cignacco Müller; (2021) Informal coercion during childbirth: risk factors and prevalence estimates from a nationwide survey of women in Switzerland BMC Pregnancy and Childbirth (2021) 21:369 https://doi.org/10.1186/s12884-021-03826-1https://doi.org/10.1186/s12884-021-03826-1

Ukoko F, Respectful care included in training, White Ribbon Alliance (June 2013). Available here: http://bit.ly/1T5uzih.

United Nations Declaration on the Elimination of Violence against Women, 48/104.  www.un.org/documents/ga/res/48/a48r104.htm

United Nations General Assembly; (2019) OHCHR | Special Rapporteur on Violence Against Women, Its Causes and Consequences; OHCHR | Special Rapporteur on violence against women, its causes and consequences and  Special Rapporteur’s New Report Addresses Abuses in Reproductive Healthcare – International Justice Resource Center (ijrcenter.org)

WHO, ‘Prevention and elimination of disrespect and abuse during childbirth’ (2015). Available here: http://bit.ly/1rmFFCs.