Recent research has shown that domestic violence towards a woman might begin or escalate during her pregnancy

A hidden crime
When Dr Susan Bewley, clinical director of Guy's and St Thomas's Hospitals, came across US research into domestic violence during pregnancy, she decided the issue needed to be addressed in the UK. 'We knew about the occasional case of abuse and violence - but once we started looking, we simply found more,' she says.

One US study showed that 37 per cent of obstetric patients were suffering abuse, and that 30 per cent of domestic violence actually started during pregnancy. Domestic abuse was identified as a major health issue for pregnant women: a Yale study revealed that abused women were 15 times more likely to suffer a miscarriage.

Accessing abused pregnant women
Together with US criminologist Betsy Stanko, of the Economic and Social Research Council (ESRC), Dr Bewley designed a research programme to examine the issue of domestic violence in pregnancy. The study's objectives were to find out whether domestic violence commonly began or intensified during pregnancy and after the baby was born.

Their worst fears were realised - of the 892 women who participated in the study, 22 reported domestic violence in the course of the current pregnancy. The lifetime prevalence of domestic violence detected during research was 13.4 per cent. In the year before the study, only one case of domestic violence had been detected, and that was because the woman was admitted to A&E.

Acceptable questioning
The abuse was only revealed when midwives asked the right questions. Women are reluctant to admit to abuse without prompting. They feel embarrassed and ashamed, and often think that they are to blame. Partners accompany some women, which further inhibits disclosure.

A crucial element of the study was to find out how acceptable questioning about domestic violence was. Midwives were trained to ask particular questions, and the responses they received were examined to assess effectiveness. This screening was done as part of normal antenatal care at first booking, at 34 weeks and within the 10-day post-partum period.

Regardless of how they responded, all the women were handed information about refuges and contact numbers for police domestic violence teams. Information was also posted up in the clinic lavatories. Before the study started, a support team of social workers, interpreters and other specialists was put together to back up the midwives.

The vast majority of mothers were happy to take part. Women were more than six times more likely to disclose violence than if they were left to mention it without being prompted. Many of them said it was a relief at last to be able to tell someone, and that it made them think about making changes to their lives.

Domestic violence as a risk factor for pregnancy
Violence in pregnancy is a serious healthcare issue. Women victims are far more likely to describe their pregnancies as unplanned and unwanted. Abused pregnant women are at increased risk of miscarriage, infection, pre-term labour, placental abruption and low-birth-weight babies. This is obviously in addition to serious physical and mental problems for the woman herself including substance abuse and non-attendance for antenatal care.

The most recent Confidential Enquiries in Maternal Death - a document prepared every three years by the Department of Health - acknowledged domestic violence as a cause of maternal death for the first time.

The report recommended that, 'A sensitive enquiry about domestic violence should be routinely included when taking a social history (during pregnancy). Ideally this information should be sought in the absence of the woman's partner. Advice or information about local sources of help should be available'.Why does it happen?

According to Betsy Stanko, 'Domestic violence is all about power and control.' The man will suspect that his partner's attention is elsewhere, and these feeling might become uncontrollable, leading to a violent response. This can intensify after delivery as the woman's relationship with her baby becomes more concrete.

'That concentration on the baby vital for the survival of the species takes the woman's attention away from the man, which can lead to the man losing control,' says Dr Bewley.

Help is at hand
A pregnant woman suffering from domestic violence can be accessed more easily than other abused women, because virtually 100 per cent pass through the health service.

'Her life changes when she becomes pregnant,' says Dr Bewley. 'And we have the opportunity to change her life.'