Chapter 23 Vulnerable women

• understand the importance of the mother–midwife relationship and what midwives can do to support vulnerable women

• realize how the wider determinants of health may affect pregnant women and their babies

• appreciate the effects of being a pregnant teenager

• be aware of the effects of drug and alcohol misuse in pregnancy, signs of domestic abuse and the type of questions to ask

• realize the importance of signposting women to appropriate agencies and services for further information and advice.

Introduction

Women who find themselves disadvantaged may have multiple social needs that affect their uptake and use of maternity services (DH 2007a). This chapter will provide an overview of the particular needs of these women and some introductory pointers to raise awareness and ensure that the most vulnerable women and those with chaotic lifestyles receive appropriate maternity care. The UK National Service Framework for Children, Young People and Maternity Services, Standard 11 champions the importance of inclusive maternity services (DH 2004a).

Domestic abuse

Domestic abuse can be defined as:

‘Any incident of threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional) between adults who are or have been intimate partners, or family members; regardless of gender, sexuality, disability, race or religion.’

(BMA 2007:1)

The term domestic abuse also includes a number of issues more prevalent in minority ethnic groups, such as forced marriage, female genital mutilation/cutting and ‘honour crimes’.

Key facts

• Domestic abuse forms a quarter of all violent crimes in the UK.

• 14% of maternal deaths occurred in women who had told a health professional they were in an abusive relationship.

• 20% of women in England and Wales assert that their partner has physically assaulted them.

• In 2003–2004 nearly all the female homicide victims were killed by their partner or ex-partner.

• At least 30% of cases first start in pregnancy.

• 40–60% of women are abused during pregnancy.

• Domestic abuse is a child protection issue (Lewis 2007).

Domestic abuse is underreported, mostly due to fear of reprisal, stigma and a continued relationship with the perpetrator, therefore any statistical data need to be interpreted with caution.

Domestic abuse is a major public health issue as during pregnancy it may result in direct harm to the pregnancy, such as preterm birth (Newberger et al 1992) antepartum haemorrhage and perinatal death (Janssen et al 2003), and also indirect harm through a woman’s inability to access antenatal care (NICE 2008). Domestic abuse has long-term consequences upon a woman’s mental health, with increased likelihood of the victim suffering from anxiety, depression and psychosomatic symptoms (BMA 2007).

A number of professional and governmental bodies, including the Royal College of Midwives (RCM 1999), the British Medical Association (BMA 2007), the Royal College of Obstetricians and Gynaecologists (RCOG 1997) and the Royal College of Psychiatrists (RCPsych 2002), advocate that all pregnant women should be asked about domestic abuse. This should form part of the needs, risk and choice assessment at the booking visit. Suggested questions include:

• ‘Are you afraid at home?’

• ‘Has your partner ever hit you?’

• ‘As an adult have you ever been emotionally or physically hurt by your partner or someone important to you?’ (DH 2005).

The process of routine enquiry for domestic abuse has been shown to be acceptable to women (Ramsay et al 2002). By asking all women and explaining it is a routine question, it helps to destigmatize domestic abuse and it also gives ‘permission’ for the woman to disclose at this time or at a later date.

All women, regardless of disclosure, should be provided with information and contact helplines for support and advice. Where a partner or other person is present, the question should be asked at a later date or an excuse found for the midwife to talk to the woman alone. In situations where a woman does not speak English, the question should be asked through an interpreter and not a family friend or relative. Where possible, the interpreter should be female and have received some instruction on domestic abuse.

A midwife’s role is to let the woman know that she can disclose if and when she is ready. The midwife should refer on and not act as a caseworker for the woman.

It is important that a woman reaches her own decision about what to do. It may be that the woman:

• calls a helpline

• contacts the police

• gets legal advice

• seeks emergency accommodation

• returns temporarily to her abusive partner after making a safety plan.

Midwives need to be vigilant and sensitive to possible indicators of domestic abuse, including:

• late booking or poor engagement with antenatal care

• repeated presentation to services or frequent unexplained admissions

• depression, anxiety and self-harm

• injuries of different ages, especially to the neck, breasts, head, abdomen and genital areas

• pelvic pain, frequent urinary tract infections, vaginal infections and sexually transmitted diseases

• partner always present during appointments and dominates the questions

• woman appears evasive or reluctant to talk

• poor obstetric history – repeated miscarriages, terminations, preterm labour, stillbirths or low birthweight babies; the pregnancy may also be unplanned or unwanted (DH 2005).

Documentation of the issues or concerns is imperative, but this should not be in the handheld notes. Confidentiality is important, but, where there is multi-professional working, it is important that information is shared. There are limits to confidentiality. If there are reasons to suspect children are at risk, safeguarding and protection takes precedence. This needs to be explained to the woman.

The Home Office guidance (Taket 2004) recommends the following mnemonic to aid the approach:

R Routine enquiry

A Ask direct questions

D Document findings safely

A Assess women’s safety

R Resources – give women information and respect their choices.

Reflective activity 23.1

What ethical dilemmas can arise for the midwife when a pregnant woman with two other young children refuses to discuss the domestic abuse she is experiencing?

Drug and alcohol misuse

The risks of physical, psychological and social harm for women who have significant problems related to alcohol and drug use during pregnancy are well documented (DH 2007b). It is also potentially harmful for the baby. Whilst the risks associated with smoking during pregnancy are also recognized, they are not covered in this chapter (see Chapter 19). There are a number of illicit substances used by women in pregnancy, including cocaine, heroin, cannabis and benzodiazepines. Poly-substance misuse – for example, opiates and alcohol – is not uncommon (Lewis 2007).

Substance misuse is often compounded by other factors, such as poverty, social exclusion and homelessness (Kaltenbach & Finnegan 1997). Pregnant drug-using women are therefore at increased risk of poorer general health and other health-related problems, including bloodborne viruses, such as hepatitis B and C. They should be cared for as part of a wider integrated multi-professional team which includes addiction, neonatal and social services.

Substance misuse during pregnancy increases the risk of poor pregnancy and newborn outcomes (DoH 2007b), including:

• placental abruption (Hulse et al 1998)

• stillbirth and neonatal death

• preterm delivery and intrauterine growth retardation (Gillogley et al 1990)

• low birthweight and sudden infant death syndrome (Hepburn 2005)

• neonatal abstinence syndrome (Shaw & McIvor 1995)

• physical and neurological damage

• fetal alcohol syndrome (DH 2007b).

Midwives should be alert to the fact that substance misuse may be associated with past or current experiences of abuse and with psychiatric or psychological problems (Klee 1997).

Antenatal care

Substance misuse makes a significant contribution to maternal mortality, with 11% of all pregnant women who died between 2003 and 2005 having alcohol or drug problems (Lewis 2007). Women often book late. This may be owing to a number of issues, including chaotic lifestyles, poor service accessibility, fear of being judged, and avoidance of social services (Lewis 2007). The booking history should include sensitive routine enquiry about all substance misuse; this includes the use of alcohol, tobacco, prescribed or non-prescribed and legal and illegal drugs. However, for some women, pregnancy may act as a positive incentive to change substance-misusing behaviour.

If it emerges that a woman has a problem with drug or alcohol misuse, she should be encouraged to attend addiction services, or specialist maternity services where available. Antenatal services should arrange a multi-professional assessment of the extent of the woman’s substance use, including type of drugs, level, frequency, pattern, and method of administration, and consider any potential risks to her unborn child from current or previous drug use.

Intrapartum care

Routine care during labour should be provided, with careful observation of mother and fetus for signs of withdrawal. Commonly seen symptoms in the mother include restlessness, tremors, sweating, abdominal pain, cramps, anxiety and vomiting. In addition, the fetus is at increased risk of hypoxia and fetal distress, as the effects of drug misuse can cause placental insufficiency (DH 2007b).

Postnatal care

All mothers and babies should be transferred to the postnatal ward unless there is a medical reason for admission to the special care baby unit. Breastfeeding should be promoted where possible; however, this is contraindicated if the woman is:

• injecting

• using poly substances

• using crack, cocaine or large doses of amphetamines

• HIV positive (Day & George 2005).

Neonatal abstinence syndrome (withdrawal symptoms) occurs in 55–94% of neonates exposed to opiates in utero (American Academy of Pediatrics Committee on Drugs 1998). Commonly seen symptoms include sneezing, poor feeding, irritability, high-pitched cry and tremors (Shaw & McIvor 1995). Hyperphagia can also occur, usually associated with weight loss, but occasionally with excessive weight gain (Shephard et al 2002).

Close follow-up and multi-agency support to keep women in treatment programmes is essential; this is particularly significant if the baby is removed from the woman. Relapse can be a problem and the latest Confidential Enquiry into Maternal and Child Health (CEMACH) report highlighted that a majority of women who died with known alcohol or drug misuse problems did so after 42 days postnatally (Lewis 2007).

Safeguarding children

It is estimated that there are between 250,000 and 350,000 children of problem drug users in the UK (Home Office 2003), representing 2–3% of children under the age of 16 in England and Wales (Lewis 2007). Midwives and addiction services need to be aware of the laws and issues that relate to child protection. If they have any concerns, they must contact their designated named lead for child protection, supervisor of midwives or social services for advice.

Reflective activity 23.2

At the booking visit, a woman who works as a barrister tells the midwife that she used to smoke cannabis but stopped when she discovered she was pregnant. She subsequently misses two antenatal appointments. When you ring her to find out why, she states that she has been extremely busy at work. She is quite dominant in her personality and promises you that she will attend the next appointment. She doesn’t. What action would you take?