 And she's currently the Director of Nursing and Midwifery Education and Director of the Women's and Nibbon Research at Griffith University and the Gold Coast. And she's going to talk to us today about domestic violence, so handing over to Kathleen. Are you there Kathleen? Yes, thank you Hazel, just unmuting my microphone. Welcome to everybody, it gives me great pleasure today to present to you on such an international audience and play a part in the virtual day of the Midwife e-conference. So today I'd like to spend some time talking to you about the role of the midwife in supporting women who experience intimate partner violence during pregnancy. So the aim of today's presentation is to explore the social context of domestic violence just to give people a bit of a background, discuss the effects of violence on a woman's well-being, examine the role of the midwife in supporting women experiencing partner violence and highlight some of the practice recommendations for us as midwives. Domestic violence knows no boundaries against women, it affects women regardless of their culture and of their social status. As well as it being a gross violation of a woman's human rights, it is a global health problem and I think the statement from the United Nations Secretary General actually sums up the problem nicely and he says there is one universal truth applicable to all countries, cultures and communities, violence against women is never acceptable, never excusable and never tolerable. So because we have an international audience today, I wanted to really look at some of the global statistics just to put some context to the problem. So the WHO of 48 population studies has estimated that 10 to 69% of women will experience physical violence by an intimate partner. It's a serious cause of death and incapacity among women of reproductive age as cancer, a greater cause of ill health and traffic accidents and malaria combined. It is a translating cause of death for women aged 15 to 44 years and between 6 to 59% of women report that they're forced to have sexual intercourse by an intimate partner in their lifetime. But as well as it having health consequences, it also has an economic impact and a conservative estimate puts a welfare cost of an intimate partner violence to be around $4.4 trillion. If we include violence against women and children, then that cost rises to $8 trillion. And if we just look at Australia itself, it's estimated that the cost to the Australian economy is $9.9 billion a year and that will continue to rise if we don't start to do some system responses to the actual problem. And while we don't know enough about interpartner violence, there are two things that's very certain. First, domestic violence against women and children will impose a huge social cost as we've highlighted there. And secondly, and most importantly, there are solutions that can help to tackle some of these problems that are very cost effective. And that's why reducing domestic violence belongs on the shortlist of the world's next set of development goals. So what are the associated risks for an intimate partner violence? Well, they include being a female, having three or more children, being aged between 16 and 24 years if you're a woman or 16 to 19 years if you're a man. If you suffer from a long-term illness or a disability, including mental health issues such as depression or post-traumatic stress disorder. If you live in poverty, if you have a luck, I'm really sorry, I don't know why my slides just keep jumping about. They seem to keep moving. I'm really sorry about this, but I don't understand why this is happening. And there is an increased risk if the woman is pregnant or has recently given birth. And when a woman has more than one risk factor, it actually increases her risk factors of experience and domestic violence even more. Hey, I'm not really sure what's happened, but all my slides have just disappeared off the screen. Sorry, I'm just putting them back on again. OK, so they're back up. So I don't understand why they keep disappearing. Sorry, everybody. That's all right. Yeah, Kelly, I can see that people can do that. I'm just figuring out how that gets stopped. We'll keep going and go on to the slides at the moment. If anyone can access them at the bottom of the arrows, just try not to. Just try and let Kathleen go through them in her own speed. Thank you, everybody. The wonders of technology. So as I was saying, if a woman has one or more risk, the more risk factors a woman has, the more of an increased risk she has of actually experiencing domestic violence. And I think if we look at these statistics, look at some of these risk factors, they're actually cover a large percentage of the women that we probably care for. So being female, obviously being aged 16 to 24 years of age and having three or more or more children, often a lot of the women that we care for, too, may have a lack of social support and they may also live in poverty. And so when you put all those risk factors together, it's clear to see that some of the women that we're probably caring for are actually experiencing partner violence. So if we look at the prevalence of intimate partner violence and pregnancy and you will find throughout this presentation that I use the terms interchangeably domestic violence, intimate partner violence. And that's because depending on what organisation you're working for or what country you live in, you may find both of those terms are used or one term is used more than another. Academics and researchers will often use the term intimate partner violence, whereas women themselves and organisations that work with women will still use the terminology domestic violence. So what is the prevalence of intimate partner violence and pregnancy? I'm sorry, but the slide has just jumped back. I'm trying to get it to sync to everyone else. So when I'm pressing the sync to try and get it so that you and you and I have got. Yeah, it's Deb here. I think I'm going to reload these slides if you don't mind. I'm really sorry to interrupt you. And I think we really shouldn't press the sync button. So I'll reload them. And then if we don't touch the sync button, hopefully that will sort the problem. So can you bear with me for a moment? Yeah, sure. Sure, Deb. So while we're waiting, we've got a question here from Susie about what about aboriginality as a risk factor? Hi, Susie. Yes, definitely. We do know that aboriginality is our risk factor. We estimate there probably, as I said earlier, that domestic violence knows no boundaries, you know, regardless of social class or grouping. But we do know that there are certain groups of women that are at higher risk and aboriginal women are one of one of those risk groups. I estimated there for time at more risk of experiencing their violence during pregnancy. Has anyone got any other questions just while we're waiting for the presentation to continue? So there was a question, how do women react to being asked about domestic violence? OK, well, I will come on to talk about that a little bit more, but we do know that women don't mind being asked about domestic violence. We have the research and the evidence now that tells us that they don't mind being asked when it's asked by a knowing care and professional. And there's no difference in those women who do who don't mind between women who are experiencing violence and women who aren't. When we did our research, we found that 98 percent of women did not mind being asked about violence during pregnancy. And when we did the work with the women, they actually said they understood why midwives would ask that question because of the increased risk. So women themselves have developed a good mechanism for actually expecting that question to be asked. And teenagers are definitely at an increased risk of partner violence. We know that when they're pregnant and when they're young and especially when they're often with a much older partner, there is an increased risk of violence occurring. And we have no way of knowing on the other question, Kelly, that they have to be asked to be asked is not to be a victim. It's absolutely true because it affects women and various social groups. And women often feel ashamed. So they won't open up about this unless somebody asked them. And sometimes they may not be honest initially when you first ask them. But we don't we have no way of knowing which women might be in a violent relationship. So we have to go for universal inquiry because otherwise we could be missing people. And so Hazel, as I might slide, loaded back up. They are just checking with Deb. Yeah, it looks like the PowerPoint might have been set up to go through an autoplay where they're changing every five minutes or five seconds on their own. I think that might be the problem. But do you want to just play button and. We'll see what happens. So what's happening is they're just going through. Is that right there? I'm just sure they should stop if you just continue. Yes, if you if you continue and forward your own slides and we'll just cross our fingers and see if it goes smoothly. OK, all right. Thank you. Thank you. So just moving on quickly, because I'm aware that we would have lost some time now and that we do know that women who experience partner violence during pregnancy are a much higher risk of experiencing risk factors. And those include repeated miscarriage. We often know that women that are physically abused will have a history of a repeated miscarriage, spontaneous abortion through through injuries that they've sustained. We do know there's a higher correlation with women who request terminations of pregnancy if they're in a violent relationship. They suffer from antiparsome hemorrhage, premature rupture of membranes and premature labor also when they're in a violent relationship because of the stress and the anxiety that goes on. Women will often present with their intrauterine growth retardation. Abrupto placenta, again, from any injuries that might be sustained from physical attacks and stillbirth. And we do know through confidential inquiries, confidential inquiries that mothers and babies have been murdered during pregnancy. There is a high risk of a low birth weight infant there at 16 times more high risk of giving birth to a low birth weight infant and some of the injuries to the unborn baby are fractures and ruptured uterus liver or spleen. So one role then, how do we identify partner violence? How do we identify that women that we care in for may be experiencing domestic violence? And many health care professionals, including midwives, are not trained to identify domestic violence. And they may mislabel and misdiagnose some of the women's problems due to anxiety or some other issue, often leading to inappropriate plans or ineffective remedies. But we also know that currently there's an ongoing debate about the commitment and the effectiveness of screening. And that's because we don't really have a lot of research that tells us about what are the long term outcomes for screening for domestic violence. And so that's where the future work needs to be carried out. But we do know that in certain health settings, such as well-ruling clinics, such as maternity, that asking women routinely about abuse is good practice. But it must be acknowledged here that for some of those people experiencing abuse, they may choose not to disclose when it's asked by a midwife or another health care professional in the first instance. Or they may decide it's not the right time for them to disclose. So the last thing we want to be doing is actually to be pressurizing women to give more detail or forcing them to take a course of action. And this is where I think in midwifery care, why continuity of care is so important. Because often when a woman first meets a midwife, it's very difficult to disclose about some of those personal issues and the relationship. But as that relationship develops, then a woman will feel much more comfortable and able to disclose. So what would be the role of the midwife? Is this a really complex, difficult thing that we're asking midwives to take on? Well, it's not because we are actually in a unique position to address some of these health and psychosocial needs of women who have experienced violence. But to be able to do that, it's really important that certain minimum requirements are met because we've got to be able to do that a-effectively and certainly safely. And we may be the first contact for that woman who's ever asked such a question, who's ever taken the time to really find out issues experiencing violence. And I do think that pregnancy and childbirth is often a time of change for women. And we know from the statistics that for all women who experience domestic violence, 30% of those women will have experienced domestic violence for the very first time during pregnancy. So it could be that the first time you ask that woman, she may not be experiencing physical violence, but she may be experiencing some of the psychological violence that goes on. But it could be because of that relationship that there's already violence occurring in a psychological and emotional sense, it could lead into physical violence. And she'll remember that you asked her that question. And as your relationship develops, hopefully she would be able to be honest and be able to open up to you. And for some women as well who experience in violence, that she, as a midwife, you may be her first contact with health services. So I think it's really important that we continue to build on this work and continue to build our knowledge. And it's really important that midwives are trained to be able to do this. And but it's also important that then you know what to do with a positive disclosure, when you get a positive disclosure. So I'm going to come on and talk about some of those things now. For those of you who can access it, the World Health Organization, in recognizing that healthcare providers and particularly healthcare providers who work closely with women such as midwives have a really important role to play, have produced an excellent document and a policy guideline. And so I've put that up there for you so that you can go online and actually get this document. It's an excellent document and it will help you understand some of the issues in a in-depth way that I don't have time to talk about today. So why are healthcare professionals and midwives actually reluctant? Well, I think it is about that fear of opening a Pandora's box. So if you ask the question and the woman tells you that yes, she is in a violent relationship, I think a lot of midwives are really fearful of actually knowing what to do next. They're often fearful of causing offence. Some may even believe it's not the province of health services, even though we know that women who experience partner violence are three times twice as likely to experience depression, twice as likely to abuse alcohol and illegal substances. So I think health we're actually dealing with a lot of the consequences. So I think it's important that we're now seen to be proactive. And we're predominantly female profession and if we know that domestic violence affects one in four women, then it's possible that we ourselves may have experienced domestic violence at some point in our life and may therefore find it very difficult to actually go there with a woman. But there's some really safe practice guidelines that we need to think about if we're actually going to start asking fair women. And that is please only ask women when it's safe to do so. And therefore, knowing how to ask the question involves attending training workshops, practicing how to ask, but what's really important and what women want us to do is be very clear about what we're asking and be confident when we're asking the question. Because if we come across as asking the question in a shameful way, then women feel ashamed too. It's really important that we listen carefully and we respond constructively to a positive disclosure. We consider the woman's safety and her children's safety and you consider our own safety. It's really, really important that you do not put yourself at risk. If, and being fearful of a positive disclosure, I've heard me do I say to me, so what do I do if a woman tells me yes, that she's experiencing domestic violence? The three simple things that you can do, we affirm a positive disclosure. So what I hear, what you're telling me is. And then it's really important to say to her, I'm sorry to hear that this is happening to you. How would you like me to help? Is there any information you need? There are support services that can help you. But it's also really important that you document if you've got a positive disclosure, but the documentation has to happen in a safe way. And certainly in the UK, they have handheld notes. So you would never document a disclosure about partner violence in a woman's handheld notes because that would put her at more risk. But it's really important that you document somewhere. And I put on the slide there about some of the things that's really important to document. And people often say to me, well, how do I ask the question? What's the best way to ask this question? Well, I've already said that it's really important to be confident and to be very clear about your asking but I really believe there's no script that fits all occasions, but just really focus on direct questioning. And if your messages are unclear, the woman may misinterpret your message and the opportunity for her to disclose to you will actually be lost. I absolutely believe confident questioning is the key. And if you don't feel confident about what to ask or how to ask, then discuss it with more experienced colleagues who may have some good ideas and some suggestions about how you can ask the question. So I've already said, responding to a positive disclosure, just once again, we affirm what she's telling you, tell her that you're sorry to hear that she's living with abuse. Really important thing to say as well is that you believe her because for many years she may have been living with a partner who will say, well, even if you tell someone, I'll never believe you. So it's really important to say that you believe her and thank her for being courageous enough to tell you about the abuse. And then ask her what she would like you to do. Now, you will have some professional guidelines that you'll have to work with, but it's really important that she's involved in the decision-making about what you're going to do. Where it becomes more complex is when there's child protection issues involved and if you feel children at risk, then you have a very clear pathway about how you should deal with them. But the woman should be involved in the decision-making that you will make about her disclosure. Again, documenting a positive disclosure is really important and again on this slide is just some of the things that you really need to think about when you're actually documenting it. Safety assessment is really important. Is it safe for her to go home and you will make that decision with her about her safety? But what we do know is that there's certainly some barriers for midwives when it comes to asking women about partner violence. And some of those barriers are a continued presence of a partner. A good practice is always, always to ask the woman when she's on her own. You would never ask in the presence of a partner. But I think in maternity services now, we've worked very hard to be very inclusive and that's the right way for us to practice. But we do know then that sometimes it can be very difficult then to be able to actually get a woman on her own and be able to ask her this question. And so perhaps what we do need to think about is how do we manage that situation then? How do we get women to be on their own for a certain amount of time on her appointment or to have a one-to-one appointment with her? We also know there's some organisational barriers. So lack of privacy, we know that some midwives don't always have a very private room, consultation room. I mean, you know that midwives are very busy and when we were listening to some of Ali's talk, we, some of the comments were that, you know, how do you do all we have to do in such a short space of time? I know from talking to midwives that they don't always have a clear referral pathways in place. So developing your guidelines and your policies and your referral pathways are absolutely essential before you would start to conduct any of this work. For women whose first language may not be English, then we know in countries like Australia and the UK there's a lack of translation services and interpreter services. And we also know there's a lack of support for midwives to do this work. All midwives should be trained and they should have ongoing support to do this work and we do know that that is not happening. I think some of these, I'm just going to move on now because I know that we're running behind because of the slides. So what's the impact of research? Where are we now in this work in 2015? Well, we do know that women do not might be asked about partner violence. So I think we know that we should be doing this work. We know that for all women who experience domestic violence, 30% of those who are in the very first instance of domestic violence will occur during pregnancy. We also know that if there's violence occurring in a relationship, it will escalate during pregnancy. We know now through research that women's wives are trained and given support to do this work. They do this work very, very well. Then in the UK, nice guidelines have now been produced. Again, reinforcing the importance of this work and how as midwives and healthcare professionals we should be responding effectively to this work. So the implications for practice are that as midwives we must strive to develop an open trusting relationship and create opportunities for women to talk about their experiences of violence. There has to be a sustained commitment to universal inquiry, but therefore midwives must become skilled in their communication. So that women do not experience midwives are asking them about a history of partner violence. There's nothing more than a tick box exercise. And we have to work up and find a way to offer women confidential time alone with a midwife. We know this is happening in many areas, but we must continue to make sure that education about all aspects of domestic violence is implemented in all our undergraduate curriculum. And that the form of this education should take a multi-agency approach. And the reason why I say that is because when women experiencing domestic violence we don't respond as a single agency. We respond as a multi-agency. So the approach that we do around the education should also be multi-agency. There needs to be a continued commitment for education and training for all qualified healthcare professionals, including midwives. And the link should be made to other aspects of safeguarding, including child safety. It's really important that training programs that are evaluated and that them should be skill based and then evaluated for their efficacy. But we do need further research in this area. We need more quantitative research, exploring the dynamics of a trusting relationship between a woman and a midwife. I think as a midwife we already ask women such personal questions. And so, but there does seem to be some form of barrier around asking women about domestic violence during pregnancy for many midwives. We need to continue to build on our research to develop a deeper understanding of violence against women and children. And presently, most of that research is focused on prevalence rates, detection rates and the negative health consequences of interpartner violence. There's a gap in the evidence and respect to effective interventions. We need to know what works well. So we need to build on that body of work around what is the long-term outcome of doing routine inquiry in pregnancy by midwives. We need to know what difference does that make to women's lives. And therefore, we have to bring women's subjective accounts into the effectiveness of that referral pathway. So to conclude, I think this is an excellent summary. We have some of the tools and the knowledge to make a difference. And those same tools have been used successfully to tackle our health, other health care problems. Domestic violence, interpartner violence and abuse is often predictable and it's preventable. And therefore, we should be working very hard to try and respond effectively. And I have just some references. So thank you very much for listening. I'm so sorry that we had an issue with slides. I'd really like to answer any questions that I can now. Thank you. Does anyone got any questions or you can put your hand up or you can type it in the chat box. Thank you very much, Kathy. That was a very interesting informative session. I'm sorry, again, about the slides. We'll just see if anyone's got any questions. Allie, do you have any recommendations for places to have this education in Australia online or otherwise? Thank you, Allie. Well, here in Queensland, the goalposts were just about to start a training program for midwives. And part of that training program will be, obviously, face-to-face training. We're planning on a six-day face-to-face training, but what we hope to do is actually put it as our online tool as well. But the work we did in the UK, we found that the thing that midwives valued the most was actually the opportunity around skill development. So the opportunity to work in small groups and practice asking the question and having the opportunity to respond when someone in that group would give them a scenario that said they were in a violent relationship. And so when we evaluated the training that we had done, we had certainly changed the attitudes. We had certainly increased knowledge and we'd certainly increased confidence. But what the midwives valued the most was that opportunity for that face-to-face skill development. But certainly the way forward is to develop an online resource. Any other question we've got here is, do you have any strategies for getting women alone when controlling men insist on being always present? Yes, when I've spoken to midwives over the years, a lot of them have different strategies for getting the women on their own and certainly the confidential inquiry into maternal deaths in the UK several years ago, recommended that all women should be offered one appointment on their own with the midwife. But it is very difficult because we do know that controlling men are often the men who won't leave the women on their own. So some midwives had developed very clever techniques as in having the weighing scales in a different room. And certainly in our antinatal clinic, we used to have women to do a urine specimen at the clinic and we would have blue dots in the toilet and ask women to put a blue dot on their urine pot if they wanted to speak to a midwife about domestic violence. So that worked quite well. We had quite a few women who put a blue dot on the sticker and then the midwife would find a reason to go and visit that woman at home when hopefully her partner was without. So there's no easy way. I think it is complex and it is difficult. And I think that's why we're still talking about this work instead of just getting on and doing it because it is complex and it is difficult. And so I noticed that some people are saying that they take the women off to the toilet and ask her then. And I think that's a really good idea. But then I've spoken to some midwives who say that they feel that's a hurried question, they don't feel they get the opportunity to ask it properly. And certainly when I was a practicing midwife and doing this work many, many years ago, I would, if a couple came together for the booking appointment, I would say to the partner that at the end of the appointment, I would like some time alone with them on their own, both of them on their own. So I would have the woman on her own for a few minutes and then I'd have him on his own. And I would say, you know, how are you feeling about being a new dad? You might not want to say something. Is there anything you want to talk to me about or say that you might not want it to say from to your partner? And so it didn't look as if I was purposely just getting her on her own. So you will, midwives have to find their own way of trying to do this effectively. And it has to feel comfortable and it has to feel right for you, just like there's no one script on how to ask the question because it has to feel right for you. But certainly during the training, we offer lots of different scenarios and different ways of asking that question. Excellent. Thank you, Kathleen. I think that having the partners on their own seems to be resonating well with a few people here in the chat room as a good idea. And I liked how you suggested in the training that you would do some scenarios where the midwife actually gets a yes because there might be some midwives that have never experienced what to do when the woman says yes, she has got issues. So I think that's a great, and we can still do two. And the other thing we noticed, hey, the laughter, the training, there was that midwives would say that they were very, became very good at picking up the, because they'd have the knowledge and the education around it, they become very good at picking up some of the signs that they may be, they said now, you know, we may have missed those previously. So they would then definitely try to think of a way to get that woman on her own to ask her because some of the signs were there that were alarming them. Yeah, yeah, excellent. Any other questions from anyone? So in what areas, Kathleen, could you see further research? Like what areas do you think are particularly important to get further research into domestic violence? Well, I think, you know, as I said, I think it's really important that we start to collect the evidence around for women who do disclose and that we're able to offer them some support and help what are the long-term benefits for them. And women's accounts, we do lots of research, but we don't include women in those. And I know my own PhD was talking to women who had experienced violence during pregnancy. And they often said that even if a midwife asked and the woman didn't disclose at that particular time, the fact that the midwife asked made them feel that they could tell her if the time was right. Because women do feel very ashamed. And they said, please don't stop asking us because we would never tell you otherwise. Because how do we bring that conversation up because we feel so ashamed? So the long-term outcomes for me is really important that we collect the evidence that by asking the question, certainly in the UK, by asking the question, we had a seven-fold increase in disclosure rate from women. So we know it's effective, but that was only a small pocket of research. So for me, I'd like to see a much bigger study done to record the disclosure rates if we start to ask this question. Excellent. And there's a comment here from Sarah that she's pleased to see it's starting to appear in textbooks for undergraduate midwifery students, which is, that's great. Yeah, absolutely. And certainly, I think it's also appearing on the undergraduate curriculum. People that I talk to, other academics are certainly saying that they're including it in their program. What's not effective is if you just do an hour or two hours and certainly a two-hour training session. It makes some difference, but it needs to be longer than that for it to be effective. And it's really important to have support mechanisms in place for midwives when they're doing this work, because it can be complex and it can be difficult. Yeah, thank you. Any other questions coming up? Well, I would... Yeah, that's right, there's a comment there, but having a trust in relationship with midwife before they disclose information. But I guess with our increased contingency of care programs around, and certainly, you know, that could be quite interesting looking at the effects of the contingency of care relationship and disclosing. Absolutely, absolutely. And that's so, so important. And that's why sometimes when you initially ask the question, you may not get a positive disclosure, but certainly as a community midwife in the UK, I found that as the woman and I grew our relationship, then I often would get a disclosure. When I'd been told no the first time I asked. Yeah. And then would you then be asking the same questions or would it just be coming up in conversation? Well, it would just come up in conversation, but we do know now that certainly that people are saying that we shouldn't just ask that question once, we should ask it at least two, maybe three times during pregnancy. So, but quite often, certainly many, many years ago, I would ask that question. And then the woman would say, you remember when we first met and you asked me about domestic violence? And I say, and she said, and I said, no, well, I just want to tell you now that, yes, it is happening because again, because we know that if it's happening prior to pregnancy that it will often escalate in pregnancy. So, yeah. Excellent. Thank you very much. And thank you again for your presentation. Thank you for everyone's questions and chat. I'm just going to turn off the recording now.