Abuse

Domestic violence is a global public health issue for women and children.^1,2 The Ontario Women’s Directorate defines domestic violence as follows:
“Domestic violence is a pattern of behaviour used by one person to gain power and control over another person with whom he/she has or has had an intimate relationship. The behaviour may include physical violence, sexual, emotional, and psychological intimidation, verbal abuse, stalking and using electronic devices to harass and control.”³

Sexual violence is a broad term that describes any violence (physical or psychological) carried out through sexual means or by targeting sexuality. This violence takes different forms, including sexual abuse, sexual assault, rape, incest, childhood sexual abuse, and rape during armed conflict. It also includes sexual harassment, stalking, indecent, or sexualized exposure, degrading sexual imagery, voyeurism, cyber harassment, trafficking, and sexual exploitation.⁴

Abuse can be manifested in many ways that may exist independently of one another or occur simultaneously as outlined below.^5,6,7

• Psychological and verbal abuse such as name-calling, humiliation, control of day-to-day life and social activities, threats, and/or harassment.
• Physical abuse, including punching, kicking, biting, burning, and/or threatening with a weapon.
• Sexual abuse such as forced sexual relations, unwanted sexual practices, or refusing to use (or allow use) of contraception.
• Economic abuse, including lack of access to family income, lack of financial independence, and/or lack of participation in the economic decisions of the household.

Domestic abuse occurs between two people connected by a bond that is or was romantic. This sometimes makes it more difficult to recognize and more difficult to put an end to the abuse by leaving the abusive partner.⁸ The majority of domestic abuse is perpetrated by a man against a female partner but can also be abuse perpetrated by a woman against a male partner. Abuse also occurs in same-sex relationships and can be perpetrated by either partner.

A Canadian study by Janssen and colleagues (2003) found of the 4,750 women who had a live birth, 1.2 percent reported that they had experienced physical abuse at the hands of their romantic partner during pregnancy and 1.5 percent of the women reported being afraid of their partner during the same period.¹⁰

More recently, The Canadian Maternity Experiences Survey (MES) asked women a number of questions about their pregnancy and perinatal care, including specific questions about violence (either physical or sexual) that they may have experienced in the previous two years.¹¹ In Ontario, of the women surveyed, 9.4 percent reported experiencing one or more acts of violence in the previous two years, and the abuse occurred before, during, and after pregnancy. The types of abuse reported most frequently were being pushed, grabbed, or shoved in a way that could have caused injuries.¹¹

There is little reported data on the prevalence of psychological, verbal, sexual, or economic abuse during pregnancy; it is difficult to estimate the scope of these forms of abuse during this period. These often coexist with the physical abuse and have significant effects on the woman and her unborn child’s health.

The Ontario government has developed two action plans to mitigate the negative effects of domestic abuse:

• Domestic Violence Action Plan (DVAP) for Ontario.¹²
• Ontario’s Sexual Violence Action Plan (SVAP).¹³

The table below outlines some of the signs and symptoms that might indicate a woman is experiencing abuse.^1,2,5,6,7,14 The list is not exhaustive nor does it only relate to violence during pregnancy.

Note: Many of these signs are not associated exclusively with abuse by an intimate partner and could be associated with other types of problems.
Other signs that might indicate the presence of domestic abuse include:

• Injuries not consistent with the explanation given.
• Delay in accessing prenatal care (reluctance on the woman’s behalf or imposed by partner).^15,16

It is important to note that physical injuries are not the only or the most prevalent indicator of domestic abuse. Often, a woman who is experiencing domestic abuse develops psychosomatic disorders exhibiting symptoms for which identifiable medical causes are rarely found.

The main factor for predicting abuse during pregnancy is the existence of abuse in the relationship before the pregnancy. However, it is important to remember that domestic abuse is a complex phenomenon that is difficult to predict and is explained by the interrelation between a number of factors^1,2,5,6,7,17 Simply because a woman manifests one or several risk factors associated with being a victim of domestic abuse does not necessarily mean that she is or will be a victim of domestic abuse in her lifetime.

Are women more likely to be victims of abuse during pregnancy?

Several studies link pregnancy to a higher risk of abuse and some suggest pregnancy may diminish the risk of abuse. ^{18,19,20,21,22} The risk of abuse is difficult to predict with absolute certainty. Nonetheless, pregnancy is a vulnerable time for women especially those who have experienced abuse previously. The consequences of abuse during pregnancy are significant for the woman, the unborn child, as well as the pregnancy. ^20,23,24,25

The perinatal period provides an important opportunity for prevention and intervention since women tend to see health care professionals more often while pregnant and in the postpartum period.  They may be more receptive to health messages or to disclose the abuse during this time.

What about after the pregnancy?

Abuse rarely stops after the birth. In fact, the data shows that it often increases in the postpartum period²⁶ primarily due to the stress level of new parents. Coupled with a crying baby, lack of sleep, and difficulties adapting to parenthood, this stress can contribute to an increased risk of abuse within the relationship.

What about after a separation/divorce?

Abuse can also occur after separation or divorce. An ex-partner can continue to abuse and harass even after the relationship has ended.

The table below lists the main factors that increase a woman’s risk of experiencing domestic violence at any time in her life.²⁷

The World Health Organization (WHO) stated the following in their World Report on Violence and Health:²

1. The more serious the abuse, the greater the impact on the physical and mental health of the victim.
2. The repercussions of different types and multiple episodes of abuse seem to be cumulative.
3. The effects of abuse can last long after it has stopped.

The table below, taken from the Intimate Partner Violence Consensus Statement published by the Society of Obstetricians and Gynaecologists of Canada (SOGC), lists a number of the possible health effects of violence over the course of a woman’s life.

In addition to the many health effects of abuse outlined above, there are significant effects of violence during pregnancy. Those specific to pregnancy are described in the table below; the lists are not exhaustive. One should also include Post-Traumatic Stress Disorder ^29,30 and consider the effects of abuse on the newborn and maternal attachment and breastfeeding.³¹

Women who experience domestic abuse often experience depression (antenatal or postpartum) and other mental health issues.^32,33,34,35 Health care providers should be aware of these as well as the physical consequences of abuse.

Abuse and stress

Experiencing abuse can lead to significant stress. In turn, this stress directly and indirectly impacts a pregnant woman’s health. Stress triggers the release of cortisol in the body. At frequent and very high levels, stress can have a number of negative health effects, including increased blood pressure, decreased immunity, decreased cognitive performance, and altered glucose metabolism. The stress of experiencing abuse can also lead to depression and other mental health issues.

Abuse and Post-Traumatic Stress Disorder

In some cases, stress can lead to Post-Traumatic Stress Disorder (PTSD). This is an anxiety disorder that can appear after exposure to an especially traumatic event such as abuse.

PTSD has psychological and psychiatric symptoms as well as physical consequences.³⁶ The estimated lifetime prevalence of PTSD among women who have been the victims of abuse varies considerably from one study to the next, ranging from 33 percent to 92 percent.^28,30

Babies of women who are abused during pregnancy have an increased risk of:

• Low birth weight.²³
• Preterm birth.²⁴
• Requiring continued medical care after birth.¹⁵
• Altered maternal attachment and bonding.
• Shortened duration of breastfeeding.^31,44
• Shaken Baby Syndrome/Abusive Head Trauma.

Shaken Baby Syndrome (SBS) occurs when a newborn or young child is shaken violently. Typical injuries include intracranial and/or retinal hemorrhages and fractures to the ribs and ends of long bones.³⁷ It is estimated that between 7 percent and 30 percent of babies who are victims of SBS die, and if they survive, 30 percent to 50 percent of those will develop significant neurological or cognitive impairments.³⁸

Children exposed to domestic abuse grow up in an environment of fear, anxiety, aggressiveness, and control where they are more likely to:

• Experience conflicts of loyalty.
• Experience abuse (verbal, physical, emotional, sexual).
• Have physical health problems (e.g., headaches, stomach aches, poor appetite, weight loss).
• Experience mental health problems (e.g., depression, low self-esteem, anxiety, and Post-Traumatic Stress Disorder).
• Be aggressive.
• Have behavioural problems (e.g., hyperactivity, antisocial and delinquent behaviour).
• Become socially isolated.
• Have poor communication and conflict resolution skills.
• Have difficulty in school.
• Repeat certain violent behaviours in their adult relationships.^39,40,41

Children are very sensitive to the family environment in which they live, and they learn through imitation. When children witness abuse between their parents, they may learn to behave the same way with others.

For additional resources on the effects of domestic abuse on children, the document authored by Baker and Cunningham (2005) Through a new lens: Seeing woman abuse in the life of a young child. A learning module for early childhood education programs is available at: http://www.lfcc.on.ca/New_lens_module.pdf.

If a pregnant woman says that she is experiencing abuse

It is recommended that health care professionals work with the woman to establish a plan for her safety.^5,6,14 Talking with women about safe behaviour increases the adoption of such behaviours.⁴² This personalized plan may include, among others:

• An assessment of the danger to her safety and that of her baby or children (e.g., “Do you feel comfortable going home today?”).
• Information on safety-related behaviour.
• Information about the role of child protective agencies.
• Information on available local resources and contact information.

For more detailed information about safety planning consult the RNAO’s Woman Abuse: Screening, Identification and Initial Response Best Practice Guideline and/or SOGC’s Intimate Partner Violence Consensus Statement under Professional Guidelines in the Resources and Links section.

If a pregnant woman responds that she is not being abused in her relationship and/or does not wish to discuss it

It is suggested that health care professionals strengthen the bond of trust. Some examples of statements that can strengthen the bond of trust include:⁴³

• “I’m happy to hear that you aren’t experiencing any abuse. If that ever was the case, remember that you can talk to me or to another member of the team about it.”
• “If there is ever any abuse at home, I am here for you. I will listen, and we can talk about it.”

There are a number of resources for women who are currently experiencing or who have experienced domestic abuse. These resources include health care providers, social workers, police, shelters and transition houses. For more information, see the Resources and Links section.