Many health professionals are reluctant to routinely, universally screen for abuse in pregnancy even though there is widespread recognition that abuse has devastating physical and emotional effects on the lives of women and their children. Professionals commonly cite the following reasons for not screening:

• inadequate resources
• lack of training
• "not my scope of practice"
• no time, large patient/client load
• lack of knowledge about how to respond to disclosures of abuse
• fear of making patients/clients uncomfortable
• fear of retaliation from abuser

However, women repeatedly state that if only someone had asked them in a caring and supportive manner, they may have found their voice to share what was happening to them. Specifically, women have shared their perspective that, during their pregnancies, caregivers had a responsibility to their unborn baby to look for signs of abuse, explain in a non-threatening way the impact of abuse on their health and be knowledgeable about services that could offer support or counselling.

Please note* that current research is underway looking at the impacts of Universal Screening practices on women and whether or not it is successful in reducing violence against women or if it could cause more harm. However, universal screening remains in the clinical guidelines for the American Medical Association, Society of Obstetricians and Gynaecologists of Canada, The American College of Obstetricians and Gynecologists and The American Academy of Pediatrics.

We recognize the importance of evidence-based practice and eagerly await the outcomes of this research to help guide us in our practice of screening and responding to women who are experiencing abuse.

* Reference:
Violence against women: integrating the evidence into clinical practice
Harriet L. MacMillan and C. Nadine Wathen,
Commentary, Canadian Medical Association Journal
www.cmaj.ca/cgi/content/full/169/6/570

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Routine Universal Screening involves taking the time to create an atmosphere of trust. Women require privacy from their partners and family members in order to safely disclose abuse. It is dangerous and insensitive to make any assumption about who in your practice may have experienced abuse and who has not.

Once privacy is assured, you must provide adequate time to screen for abuse and respond in a way that is supportive and knowledgeable about issues related to abuse. Make eye contact and demonstrate your willingness to listen through your body language.

What questions should I ask?

You may ask questions about her understanding of abuse:

• "Some people think that in order to be considered abused, a person has to have been physically or sexually hurt. Are you aware of the other ways in which women can be abused?"
• "In your past and/or present relationship(s), were there times when you wondered whether or not your partner was being abusive?"

You might ask questions about how she and her partner work through disagreements:

• "Could you tell me how you feel after you and your partner argue?"
• "When you and your partner argue, do you feel listened to or silenced?"
• "Have you ever felt afraid during an argument?"

You might want to include questions about childhood sexual abuse and link it with present concerns related to abuse and pregnancy:

• "Many women that I work with have experienced abuse in their lives. Some women experienced sexual abuse in their childhood or in their teenage years. Other women have been hurt or abused in an adult relationship. In pregnancy, there can be reminders about past abuse that can show up and have a negative impact. If you have experienced an event in your life that you are worried may resurface in pregnancy, labour and birth, or postpartum, please know that I am a safe person for you to talk to and I am aware of other community resources that may be useful for you should you wish to connect with them."

However you choose to ask a woman about her past, please remember that the most important thing you may be doing is helping her to break the silence. By choosing to tell you about her experiences, she may learn that there is help available and that she is not alone.

Written questionnaire or face-to-face screening?

While results of a recent study indicate that women who were being abused preferred written questionnaires over face-to-face screening (JAMA, 2006), we have found a high degree of disclosures of past abuse in face-to face screening. However, this could be attributed to the fact that a relationship of trust has been established over time with our clients, all persons asking have been trained specifically to screen and respond to disclosures of abuse, our clients tend to be seeking out services that offer them greater control (midwives, doulas) and survivors may, for this reason, be over-represented in the client population of midwifery and doula practices.

We have also heard feedback from survivors that one of the main problems with written disclosure was that they were not often followed-up with support or referrals by a caregiver. Therefore, it is important that, regardless of the method used, disclosures be honoured with the suggestions provided.

Why ask specifically about a history of abuse?

Universal Screening is NOT... reading off a checklist of abusive behaviours or including one question lumped in with other clinical questions. Women have repeatedly stated that having an abuse question grouped with questions about weight gain, diabetes, etc., is insulting and minimizes the significance of abuse in relation to their physical, emotional and spiritual well-being.

Women have shared with us that it was important that caregivers asked specifically about abuse issues. They felt that by using the language of abuse (and not dancing around it) caregivers demonstrated an understanding about abuse issues and therefore were better prepared to hear their disclosures. This didn't necessarily mean that they told the person asking the questions, but they knew that the person at least cared on some level about abuse and its impacts.

Some women will not identify with being in an abusive relationship if they are not made aware of the many forms abuse can take. It can be a powerful education tool to display Power and Control wheels (charts) in a visible place and/or show them to her with an explanation of what is represented.

For many women it may not be enough to just ask "is there anything about your past that you wish to share with me?"... this is often too broad and vague to capture that you are inquiring about abuse. They may not feel that this is what you are asking (the question could mean the death of a loved one), and therefore wouldn't want to catch you off guard. Other women felt like abuse was the "elephant in the room." They felt that there were so many obvious signs (bruises, aggressive partner, missing multiple appointments, etc.) that they resented that their doctor/midwife either didn't notice or didn't "care to ask."

What is the connection between childhood sexual abuse and abuse later in life?

Children who were abused may have a difficult time as adults setting and sticking to boundaries that keep them safe. Children learn about boundaries as they grow-up and are able to say "no"; asserting their own needs in ways that are developmentally appropriate. They communicate to the adults around them their wants and/or needs for physical space and hopefully this is respected and nourished. However, adults who sexually abuse children send different messages... such as: It doesn't matter what you want, your body belongs to me for my amusement, we own you...To cope, children learn to detach and this transfers into adulthood. Routinely detaching prevents women from truly getting to know themselves, THEIR WANTS, THEIR NEEDS. Even when the adult survivor is clearly being abused, they may have a very difficult time speaking out. Often the low self-worth, self-blame and shame that results from earlier abuse, sets adult survivors up for further re-victimization. It is therefore imperative that people understand the link between earlier experiences of abuse and the likelihood that childhood sexual abuse survivors may have on-going abuse issues in their current relationships. Just as important is recognizing that a woman who is in a current abusive relationship may also have a history of childhood abuse. Understanding this link may assist you in offering more appropriate referrals so that she can examine how the messages she learned early in her life are impacting her as an adult.

However, much more research is needed to look at the ramifications of women disclosing abuse, such as the involvement of child protection or reprisal abuse for a woman who leaves and then returns to an abusive partner. You need to consider how the information could be used against her in court in such matters as child custody. It is advisable that you seek training or information on documentation related to the abuse of women and what your professional standards require.

Before you ask, please be sure to inform her:

• that you are about to ask her some questions that you ask ALL your clients
• that the reason you ask is because you care about your clients and would have information and supports available to her should she need them
• that you ask because you know that many women live with abuse and are afraid to tell
• that her information will be kept confidential except in certain circumstances
• what those circumstances are, such as duty-to-report obligations of your provincial or state child protection agencies or if you were subpoenaed to court
• that she has the right not to answer at the present time but you would be available at a future time should she wish to speak with you

Your own safety

Be aware of the potential risks to your own safety when working with women who are being abused. Adopt personal work habits that optimize your safety and lobby your workplace to implement security measures and protocols accordingly.

If you are in private practice or work unpredictable hours (doula, midwife), think about meeting in a place other than a client's home for the first visit, let someone know where you are going and when you are expecting to return, carry a cell phone, ask hospital security to escort you to your car at night and at all times be aware of your surroundings (nearest exit, phone etc...).

"Should I be the one to ask about her past?"

Ask yourself...

• Do I have professional guidelines to follow?
• Do I have the skills and resources to respond to a disclosure?
• Do I have the time to provide support?
• Could the answer help me to provide her with better support or services?
• What obstacles prevent me from asking/responding?
• Are there any forseeable negative consequences for my client/patient for which I do not feel I could provide assistance? (in the form of safety planning, referrals)

If you answered "No" to some of these questions, it could mean you need more supervision, training or information on how to best meet the needs of women in your care who may be experiencing abuse. Speak with a colleague, supervisor or community organization for local training opportunities.

If you are a care provider who has experienced abuse...

How you bring awareness about the impacts of abuse to your patients/clients may be shaped by your own abuse history. If you have experienced abuse we strongly recommend counseling before you start screening women so that you are not inadvertently transferring your own survivor issues onto the women you are working with. Recognize that your ability to empathize with women who have been abused can be very powerful but also self-destructive if you do not receive proper support, supervision and collaboration.

Screening tools available:

• Routine Universal Comprehensive Screening (RUCS)
• Woman Abuse Screening Tool (WAST)
• Index of Spousal Abuse (ISA)
• Abuse Assessment Screen (AAS)
• Partner Violence Screen (PVS)

For further information related to screening in pregnancy, please see the following:

The Effect of Domestic Violence on Pregnancy and Labour. The College of Family Physicians of Canada. Discussion paper January 28, 2000. Commissioned by the CFPC's Maternity and Newborn Care Committee. Prepared by Lent B., Morris P. and Rechner S.

Healthy Beginnings: Guidelines For Care During Pregnancy and Childbirth. Society of Obstetricians and Gynaecologists of Canada. Clinical Practice Guidelines Policy Statement, No.71, 1998.

Also (not specifically about pregnancy):

Woman Abuse: Screening, Identification and Initial Response
Best Practice Guidelines, Registered Nurses Association of Ontario
"The overall purpose of this guideline is to facilitate routine universal screening for woman abuse by nurses in all practice settings."

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