By Diandra Daley
Domestic violence is a leading cause of death and disability worldwide, affecting one in three women during their lifetime (WHO, 2017). Women who are pregnant or have recently given birth are particularly vulnerable to domestic violence; for nearly 30% of victims, the first incident occurs during pregnancy (Rodriguez et al., 2001). The risks of morbidity and mortality posed to both mother and baby also make domestic violence an important public health concern. As many as 16% of all deaths during pregnancy have been associated with domestic violence in low- and middle-income countries (LMIC) (Ganatra, Coyaji and Rao, 1998).
Routine antenatal visits offer unique opportunities for healthcare providers to identify and refer women to intervention programmes. In high-income countries like the United Kingdom, screening and referral to these services is part of standard antenatal care (NICE, 2014; Department of Health, 2012). However, such practice is not routine in most LMIC. As a result, there is little evidence indicating what interventions may work best to recognise and manage women who experience domestic violence during and after pregnancy in these contexts.
Dissatisfied with this gap in knowledge, I was keen to explore how researchers have implemented and assessed interventions for domestic violence against women during and after pregnancy in LMIC, and evaluate the quality of this evidence.
Exploring the evidence
We therefore conducted a systematic review of the literature and identified five studies which involved 822 pregnant women. These studies described and/or evaluated the effects of domestic violence interventions on the frequency and severity of violence towards pregnant women, and a range of physical, psychological and social health outcomes.
Of the five studies, three were conducted in Africa: two in Kenya, (Turan et al., 2013; Mutisya, Ngure and Mwachari, 2018), and one in South Africa (Matseke and Peltzer, 2013). One study was conducted in India (Krishnan et al., 2012), whilst another was conducted in Peru, South America (Cripe et al., 2010). Notably, none of the included studies were conducted in countries classified as low-income by the World Bank. Therefore, we’re uncertain how applicable this evidence is to the world’s most resource-poor nations.
Unfortunately, the overall quality of these studies was limited, and they did not provide strong, high-quality evidence that a particular intervention was most effective. This was largely due to their small sample sizes and weak study designs. Nonetheless, it was reassuring to identify evidence that supportive counselling, screening and referral services may prevent or reduce violence against pregnant women, limit the psychological effects of violence, increase social support and improve quality of life for these women.
Four studies examined some form of supportive counselling, whilst one study trialled a preventative intervention consisting of screening and supported referrals. Only two of the included studies sought to evaluate the effectiveness of their interventions following their implementation (Krishnan et al., 2012; Turan et al., 2013).
This evidence suggested that counselling might be an appropriate and effective approach to providing support for women who experience domestic violence during pregnancy in LMIC. Two out of four studies evaluating different forms of supportive counselling reported a statistically significant decrease in domestic violence victimisation following counselling interventions. Counselling proved to be particularly effective for reducing physical and sexual violence inflicted by an intimate partner (Mutisya, Ngure and Mwachari, 2018, Matseke and Peltzer, 2013).
Women who received counselling also reported significantly lower depression scores, (Mutisya, Ngure and Mwachari, 2018), improved quality of life, increased use of safety behaviours and greater use of community resources. However, these differences were not statistically significant (Cripe et al., 2010). Krishnan et al., (2012) also reported improvements in family support in women who received group-based counselling.
Preventative screening and referrals
The effect of a screening and referral programme on domestic violence victimisation is unclear. However, more than half of women who screened positive for violence utilised referral services. These women also experienced increased social support and improved access to community resources.
The need for further research
This review identified promising evidence for the existence and benefits of domestic violence interventions for pregnant women in LMIC. However, it was also important to highlight drawbacks in this evidence.
There was a lack of consistency in the outcomes reported across these studies. Where studies measured and reported on similar outcomes, researchers used various tools to measure them, and at different points in time. Such differences reflect the need for context-specific approaches to measuring outcomes of violence, but also the inexperience of researchers and the lack of general consensus on how best to conduct research on this subject.
The lack of data on a number of outcomes that are arguably most pertinent to antenatal and postnatal care was also concerning. None of the studies investigated maternal health or pregnancy outcomes, such as miscarriage, antepartum haemorrhage or mortality. Also, none of the studies measured the effect of interventions on stress, anxiety and postnatal depression. Similarly, no studies investigated outcomes related to neonatal morbidity or mortality. Consequently, the effect of domestic violence interventions on these important health outcomes remains unclear.
In addition, none of the studies included women after childbirth. As a result, it also remains unclear whether the interventions available for pregnant women would be as effective in improving the health and well-being of women who experience domestic violence after childbirth in LMIC.
Supportive counselling, screening and referral programmes show promising results for reducing domestic violence victimisation and promoting improved psychosocial health. However, more large-scale, high-quality research is required to provide further evidence for the effectiveness these interventions, and to address gaps in evidence that this review has identified.
Although the included studies did not examine important maternal and neonatal health outcomes, the positive psychosocial outcomes reported from these studies confirm that domestic violence interventions should be integrated into routine healthcare worldwide; particularly in LMIC, where women have a substantially greater risk of being abused. These interventions must be context-specific, culturally sensitive, and effectively address the needs of women.
The burden of domestic violence among women during and after pregnancy is growing exponentially. To effectively address this global health problem, it is imperative that further research is prioritised.
About the Author
Diandra Daley is a medical student at the University of Liverpool, who intercalated at LSTM in the academic year 2017/18. She has interests in women’s health and mental health, and has conducted research in these areas. Diandra was supervised by Dr Mary McCauley during her Master’s research dissertation.