Perinatal

Prevalence of Violence Against Women During Pregnancy

Women who are abused appear to be at a higher risk for abuse during pregnancy. The consequences to women and children's health due to this perinatal violence are significant. This review of the literature will explore the prevalence of violence against women during the perinatal period and will describe the current health care responses. It will examine some of the dilemmas found within health care practice including cultural issues and legal considerations. Finally, it will identify areas for further study.

Prevalence of Violence Against Women During Pregnancy

Estimated rates of violence during pregnancy vary depending on the study design and the women selected for that study. It is commonly estimated that between 4% and 17 % of all women are abused during pregnancy (Cokkinides, 1998; Gazmararian, 2000; Stewart & Cecutti, 1993). In a 1993 survey of women who had reported abuse by their partners, 21% of those women indicated that they were abused during pregnancy and of these women, 40% of them said that the abuse actually began during pregnancy (Health Canada, 1999). Stewart and Cecutti (1993) found that in a study of abused women, 64% of women responded that the abuse increased during pregnancy. Stewart (1994) also found that for 95% of a sample of women who were abused during the first trimester, the abuse increased after the baby was born. In particular, young pregnant women appear to be at a higher risk for abuse by their partners. It has been estimated that one in every five pregnant teenagers experiences physical, sexual and/or emotional abuse. Studies in Canada, the United States and Australia have found that 23 - 37 % of teenage women reported physical abuse during the year of their pregnancy. (Curry, 1998; Martin, 1999; Parker, 1993; Worcester, 1992). In studies comparing their risk to the risk of adult women, the teenage women were found to be at significantly higher risk, and reluctant to disclose the violence to adults (Parker, 1993; Webster 1994). For many teens, the abuse had started when they discovered they were pregnant. Most alarming, 65% of the battered teens had not told anyone about the violence in their lives (Worcester, 1992). Teens who experienced violence were also more likely to use multiple substances resulting in further pregnancy complications (Martin, 1999).

The consequences of perinatal violence include serious birth outcomes such as low birth weight, miscarriages, and prenatal exposure to drugs and alcohol (Newberger, Barkan, Lieberman, McCormick, Yllo, Gary, & Schechter, 1992). Battering during pregnancy also tended to be of greater severity when correlated with other significant problems such as lack of social support, and problems in obtaining such necessities as housing (Campbell, 1992).

Battered women are regular users of the health care system, but they are poorly identified. Between 22 and 37% of women who use emergency room services are battered (Family Violence Prevention Fund, 2001).

Although health care workers do not regularly ask about battering during pregnancy, it is more common than, and has as serious consequences (increased rates of miscarriage, stillbirth, low birth weight babies, and risk of homicide) as the conditions routinely tested for in prenatal care (Worcester, 1992:284).
Recent research also confirms that abuse during pregnancy is more common than other conditions routinely screened for, and that current procedures for identifying abuse are inadequate (Connolly, 2000). Women whose pregnancies are unplanned are at even higher risk and in some instances, the unplanned pregnancy is a result of a sexual assault by their partner or their partner's controlling their access to birth control.

It has been estimated that only 8% of women who are abused by their partners have contacted a transition house, while 40% of abused women have contacted a doctor or nurse for medical attention (MacLeod, 1996). Women who are abused access health services more frequently than women who are not abused. Clearly health care providers interact with battered women more often than any other services, and offer the most frequent opportunities to address this violence.

Current Health Care Responses to Battered Women During Pregnancy

The province of British Columbia has the highest reported rate of violence against women in Canada, but currently has no overall health care strategy to respond (British Columbia Ministry of Health, 1999). Health care professionals often do not recognize violence against women and recognize it even less during pregnancy. Although 66.7% of battered women received medical care for abuse, only 2.8% of those women who were abused during pregnancy, told their prenatal care providers about the abuse. Pregnancy may be the best opportunity for health care providers to identify abuse in a woman's life because it is the only time in her life when she is receiving regular health care.

In the United States, all accredited hospitals must have protocols outlining how they respond to battered women. Different programs in the United States are described in Best Practices: Innovative Domestic Violence Programs in Health Care Settings put out by the Family Violence Prevention Fund. They include Womankind, a hospital program based on a comprehensive integrated case management model that works with abused women and provides services from several months to several years. They also include training programs such as Radar, a multidisciplinary group that trains health center staff (Nudelman, J., Durborow, N., Grambs, M., & Letellier, P., 1997).

In Canada, Hotch, Grunfeld, MacKay, & Ritch (1996) conducted a national survey of hospitals to determine three areas of responses to woman abuse in Canadian hospitals. First, they wanted to know the proportion of Canadian emergency departments with domestic violence intervention policies and procedures, second, how hospitals identify and provide service to patients who have been abused, and third, what approaches have been either problematic or helpful in implementing domestic violence protocols in emergency departments. There is considerable variety across Canada. 39% of hospitals reported having specific policies or procedures concerning the care of patients who have experienced domestic violence. Universal screening for domestic violence was reported by 13% of the hospitals surveyed. On-site counselling was provided by 23 %. Only 6.4% reported a policy that required all cases of domestic violence to be reported to the police.

Vancouver General Hospital instituted a Domestic Violence Program in their emergency department in 1992 (Hotch, Grunfeld, Mackay, & Cowan, 1996). All women are screened at triage, and if abuse is disclosed, they are moved into a safe care area. Although 6% of women who are screened are identified as abused, that 6% falls short of the estimated 22 - 37% of women who come to emergency services as a result of abuse. One of the purposes of this program is to provide follow-up care. However, of the patients who disclosed abuse, only 55% of them were actually contacted later. The other 45% could not be reached or declined follow-up services. Of the 55% contacted, only 29% of those women received three or more contacts following their visit. Therefore, it is recommended that because nearly half of the women who have been abused, decline follow-up services, it is important that emergency staff are trained to provide referrals and information at the time of the emergency visit (Hotch et al, 1996).

This emergency program is significant, considering the research that describes battered women's experiences in emergency departments. One study found that half of the battered women accessing emergency services described negative experiences there. These experiences included "feeling humiliated, being blamed for their abuse, having abuse minimized, being given insufficient referrals, and not being identified as battered women" (Campbell, 1994: 280).

At BC Women's Hospital, the Woman Abuse Response Program has integrated a comprehensive approach that responds to violence against women in relationships (Cory, 2001). This program works in coordination with the broader community of services for women who are battered. The program has developed clear clinical guidelines to ensure that the woman is empowered, safe, and trusted to know what is best for herself. What began as a process of providing staff with domestic violence training and implementation skills has transformed into a process of shifting attitudes and social change.

This shift is the core dilemma in instituting practice change in our medical and social communities. We are sitting on the cusp of a vital alteration that appears to contradict the established medical model of care that predominantly works with reducing disease and illness to a manageable category of physiologically based concern while delegating symptoms into narrow bio-medical diagnosis. Inherent in this model is the assumption about women that they are deficit, dependant, unable to make decisions, problematic and to blame for their situation Cory, 2001).

A women's- centered model however, demands that we move away from a fractionalised, objectifying model of intervention for women's health and towards a more empowering and respectful process of care. It includes key elements that can redirect our attitudes and work. These include:

Four elements that address processes that engage and empower women:
The need for respect and safety
The importance of empowering women
Involvements and participation of women
Collaborative and inclusive work environments
Four elements that recognize gender differences that affect women's health and access to health care:

Women's patterns or preferences in obtaining health care
Women's forms of communication and interaction
The need for information
Women's decision making processes
Three elements that explain methods that support women-centered approach:

A Gender inclusive approach to data
Gendered research and evaluation
Gender sensitive training
A final element that discusses systemic inequalities that affect women's health and services:

Social justice concerns
(Vancouver/Richmond Health Board, June 2001)

The medial model promotes the screening of violence and referral of women to appropriate resources while the women's centered model promotes the acknowledgement of women's right to access and utilize care that addressed their whole being as integral to their health. At the crux of this basic dilemma is conviction that screening and referral are not sufficient to ensure safety for women and their children.

Other Important Dilemmas for Health Care Providers

Health Care providers face their own barriers responding to battered women. Some health care providers are themselves, in abusive relationships. As a result, feelings of discomfort may arise. Some health care providers believe that even if a disclosure is made, there are simply not the appropriate services available in the community to respond. For example, there may be a lack of appropriate resources for pregnant teens experiencing violence because teenage women who are battered are less likely to access services for adult battered women. Some health care providers identify lack of training as a barrier. Others experience the dilemma that they are treating both the abused and the abuser as patients. In some cases, the abusers may even intimidate health providers (Health Canada, 1999).

The lack of power that nurses may have in their own lives -both personally, and professionally, in the hierarchy of the institution - may play a role in how nurses respond. Nurses must not be blamed for failing to screen when their reasons for choosing not to screen are equally valid, but seldom heard. A structural analysis of the nurses' dilemma follows:

Few of the projects look at power dynamics in institutions, and when they do, it tends to be in the context of power dynamics in a relationship between two people. Further, the emphasis on awareness-building in most of the projects means that many of the projects tend to equate power-based barriers with lack of awareness about violence, rather than looking at other values, attitudes and institutions that perpetuate power imbalances and that also may perpetuate woman abuse. The result of this emphasis is that existing projects rarely try to influence structural change directly, even though a need for such an approach has been identified. (Macleod,1994:38).
Much of the research critiques nurses' responses to violence against women (Campbell, Pliska, Taylor, & Sheridan; 1994, Dickson &Tutty, 1996). Some nurses have questioned whether asking questions about abuse without the context of a trusting relationship is effective. Some nurses have expressed concern that asking questions about abuse may offend the woman. What is lacking in the literature is a critical analysis that describes the situation from the nurses' perspective. It is likely that the nurse's decision not to ask about abuse is based on complicated factors. What may appear to be a failure to screen for abuse may instead be a conscious decision that disclosure at that moment could further endanger the woman's safety. Because confidentiality on maternity charts cannot be guaranteed, concerns have been raised that documentation of abuse without the woman's consent puts her at further risk. Cory writes:

We will not assume that disclosure of abuse is the goal, but rather that the practitioner will recognise a myriad of elements of abuse that are revealed through a woman's health condition, and that she will receive safe care, accurate information, treatment and advice and that she will have been assisted to make the connection for herself between the abuse that she is exposed to and her health concerns. (2001, unpublished).
Warshaw (1997) points out that many aspects of medical training are also abusive. She describes the demanding and debilitating schedules and peer isolation on clinical rotations. Other abusive aspects of medical training can include lack of validation during emotionally upsetting situations, harassment from attending physicians, and a failure to make medical staff accountable for their behaviors towards medical students. She writes, "Recognizing the potentially abusive aspects of medical training and the importance of creating environments that do not permit such behavior is important not only in improving the health care response to domestic violence but also in creating a society that does not tolerate abuse" (p533).

The dilemmas which physicians struggle with are significant (Rittmayer & Roux, 1999). These researchers described one dilemma was feeling "remiss for not diagnosing abuse or for not improving the patient's condition if they made the diagnosis" (p 169). The doctors also found themselves without guidelines for treatment, and the interventions they proposed often contradicted the recommendations in the literature. When the physicians were treating both the woman and her abuser, they sometimes worked toward goals of maintaining the family as a whole, rather than assessing what is in the best interests for the woman's safety. Their study found that physicians became frustrated with women who were not compliant and did not follow their advice concerning their abuse. The researchers identified three phases that would help physicians relinquish their need to "fix-it". The first step was to accept that making contact with the abused woman was a success in itself. This required that the doctors let go of their own agenda for what the woman must do. Second, doctors had to redefine their own role. Empowering the woman and respecting her choices became the goal, rather than feeling the need that the woman should follow their recommendations. Third, doctors needed to work towards forming partnerships with the woman. Physicians began to understand that training within the medical community and medical schools was inadequate and needed to be reformed.

These researchers concluded that the medical model put doctors in a double bind because "domestic abuse was presented as a medical problem that they must treat, but they knew it was a social problem that they could not hope to cure" (Rittmayer & Roux,1999: 178). Many of the doctors in their study, were misinformed about state reporting laws, and lacked a comprehensive awareness of the importance of their documentation if a case was prosecuted. However, a reluctance to document the abuse could also reflect an astute awareness of concerns around prosecution and the inevitable lack of confidentiality in the legal system.

Warshaw suggests that the pressure to make rapid assessments, diagnoses, and treatment recommendations can result in doctors feeling urgency to take charge and maintain control of the situation. But for battered women, who are already controlled and dominated by their partners, this further disempowers them.

The medical model, in fact, can only "medicalize", reduce things to categories it can handle and control. The need to control and reduce is inherent in its scientific and epistemological base.�The issue of battered women is a subversive one. In order to take it on fully, medical staff risk losing control in ways that the model normally protects them from; having to deal with unpleasant, potentially overwhelming feelings that are often evoked by actually listening empathically to a patient; and having to deal with agencies and institutions that are outside the control of medicine and that often have a critical perspective on the delivery of health care. Most important, they risk having to change the doctor-patient relationship itself, a relationship in which the unacknowledged need to maintain control and power reproduces an abusive dynamic antithetical to the care a batter woman most needs (Warshaw, 1989: pp.143-144).
Health Canada (1999) offers guidelines for physicians reporting and documenting abuse that may be used in court, but a critical analysis of the underlying legal issues is lacking. This Health Canada report also offers recommendations for physicians whose patients include both the abused and the abuser. Although it does not recommend conjoint counselling, it does propose that the physician may provide individual counselling to each patient. Conjoint counselling is suggested only if the violence has ended, which is often difficult to determine. These practices would be described by service providers working with abused women as disempowering for the woman, and as putting her at further risk. Instead Warshaw suggests:

Learning to help a battered woman assess her level of danger and options for safety requires a tolerance for facing the terror and danger with her, while knowing the limits of the systems designed to protect. Not abandoning her in a process the clinician is unable to change is very difficult. (1997: 534).
Cory (2001) found that in her work with women who are abused, although most women gave extensive details of the health effects from violence, they seldom considered the relationship between the health effects and the abuse. They may have worried that they were losing their memory, having a heart attack, or stomach cancer, but they were reluctant to disclose their worries for fear of being labelled as crazy. She describes situations where women, who were unable to follow their physician's advice due to their partner's control over their activities, were labelled as non-compliant. Women may also be labelled as having low self-esteem, and being depressed, or unstable, rather than understanding that these characteristics are the result of the abuse. In another study, physicians treated identified battered women differently than non-battered women, which contributed to the problems the women faced. One in four battered women was described in their records as neurotic, hysteric, hypochondriac or a "well-known patient with multiple vague complaints" (Worcester,1992: 286). One in four battered women was given pain medications or tranquilizers compared to one in ten non-battered women. Worcester stresses that rather than giving battered women psychiatric labels or tranquilizers, health care providers must ensure that safety issues are addressed before she returns to the situation that is causing her injuries. Rather than viewing the patient as pathologic, the situation must be reframed to view the pathology as the abuse by her partner and "the social, cultural, and political-economic structures that sustain, support, and mediate its impact. (Warshaw, 1997:528).

Cultural Issues

Although there is research on culturally competent practice in working with women from other cultures who are abused, much of the work focuses on African-American women's experiences. It is difficult to find information about the barriers that exist for Asian, Aboriginal and Indo-Canadian women. Certainly battered minority women are justified in their concern that their partners live with cultural stereotypes, face discrimination, and are therefore, more likely to be jailed. There is also not enough published literature that focuses on the additional concerns that First Nations women who are abused and pregnant may face. Durst (1991) demonstrates the need for community-based solutions that are not imposed on First Nations communities without collaboration. First Nations women experience significant barriers when accessing the health care system (Browne, Fiske, & Thomas, 2000). They may live without telephones or transportation. Therefore, it is difficult for them to avoid a $20 fee for missed appointments without a telephone and it is difficult to arrive on time when they depend on others, including the abuser, for a ride into town. The history of the residential schools includes both the physical and sexual abuses that many children experienced, combined with the strict moralistic training about modesty and sexuality. The resulting sense of shame of one's body and therefore a reluctance to expose it to medical staff can be passed from one generation to the next. In addition, there can be a feeling of alienation in using health care services if there are few or no First Nations people employed there.

First Nations women describe their experiences with the health care system as either invalidating or affirming. (Browne et al, 2000). Invalidating experiences are described as being 'dismissed'. Women believed that their concerns were dismissed based upon the service provider's stereotypes as First Nations women being passive. Instead, their passivity was actually "a culturally specific way of conveying respect to people who are consulted for advice or assistance" (p14).

This combination of factors - dismissal on the part of providers, getting turned away, reluctance to admit to symptoms until they are severe, and providers' view of women as passive - creates the potential for tense or difficult health care interactions and potentially poor health outcomes for women" (Brown et al, 2000:15).
Affirming responses included affirming First Nations culture, respecting the extended family visiting for extended hours, and developing a long-term relationship. This last experience is difficult considering the high turnover of health providers in remote northern communities. Certainly, the added crisis of violence during pregnancy complicates the issues facing First Nations women in disclosing violence and planning for their own safety.

Legal Considerations

There are significant differences between working with battered women in the emergency department and on the maternity ward. Particularly during labour and delivery, it seems that asking a woman if she is being abused, may increase the chances that the baby and her other children may be apprehended. It is a particularly vulnerable time in that woman's life.

The level of documentation required by the health system may operate as a systemic barrier to safety for some women, particularly those who have experienced violence. Women who fear child apprehension or loss of custody may be reluctant to share health information. In some cases chart information has been used against them, or charts have been subpoenaed by courts; yet women may be viewed with suspicion when they ask not to have something charted. Aboriginal women are particularly affected by a foster care/adoption cycle. About one-half of Vancouver children in care are Aboriginal (Vancouver/Richmond Health Board, 2001).
Currently the Woman Abuse Program at BC Women's Hospital is involved in a partnership with service providers for abused women. They have initiated a dialogue with the Ministry for Children and Families concerning the reporting when a woman has been identified as abused. One of their questions is whether Ministry staff in different regions or even within regions are "consistently interpreting and communicating to the community current reporting requirements, for example, by participating in local coordinating committees dealing with violence against women?" (BC Association of Specialized Victim Assistance and Counselling Programs, 2000:11). Confidentiality of information cannot be guaranteed once a report has been made to the Ministry. This remains the discretion of the courts. In addition, the abuser may retaliate with further violence when he discovers that a report has been made. Therefore, the health care provider must decide whether making a report may actually increase the risk to both the mother and her fetus. This document recommends a case-by-case approach, rather than an across-the-board policy to contact the Ministry for Children and Families. Clearly, this report contradicts those regions, where reporting is mandatory. There are differences across Canada concerning the reporting of woman abuse to the Ministry for Children and Families (MCF). The Atlantic Provinces and Saskatchewan, have changed their reporting requirement to include children living in situations of severe domestic violence as children who require intervention (Health Canada,1999).

Warshaw (1997) presents further complications with mandatory reporting:

Documentation of domestic violence in the medical record has resulted in some women's being rejected or dropped from insurance policies. Law in a few states that mandate health care providers to report injuries related to partner abuse are preventing some victims from disclosing the abuse or even seeking health care. In addition, mental health reimbursement policies that require patients to be "given" a psychiatric diagnosis in order to receive treatment place battered women in the position of having to choose between receiving mental health services and risking having this diagnosis used against them by the abuser to obtain custody of their children. (p 527).
Areas for further study

To date, much of the research has been on screening methods to identify abuse. Currently, there is concern that we need to focus more attention on whether follow-up care is available, and to ensure that the woman will be safe following our interventions. There are many creative approaches identified in the literature. McFarland (1997) proposes a "Mentor Mother" Advocacy Model to ensure those pregnant women are safe once identified. The mentors were trained through the health department and the initial training program lasted 23 hours. As well, the abused women had unlimited individual counselling provided by a social worker and monthly educational support groups. Unfortunately, this model required that the mentoring relationship end after delivery, and closure was difficult for some of the women. Again, McFarlane recommends that: "if the resource needs of abused women are to be met, long-term follow-up that includes outreach advocacy is required" (1997: 244). Young and McFarlane (1994) have also developed a National Education Model for health providers that evolved into a 21-hour experiential learning model.

More recent research has assessed the safety behaviors of abused women after an intervention during pregnancy, and this research finds that some of the recommended behaviors are not accomplished. However, it could be argued that some of the recommended safety behaviors could put the women at further risk. Convincing a pregnant woman to secretly obtain her drivers license (a time-consuming procedure that requires practice, money, and a vehicle) may put the woman at further risk if the abuser finds out. Clearly, what some define as safety behaviors that women fail to accomplish, others may define as actions that could further endanger the woman (McFarlane, J., Parker, B., Soeken, K., Silva, C. & Reel, S., 1998; see also Parker, B., McFarlane, J., Soeken, K., Silva, C., & Reel, S.,1999).

The research also focuses on public health nurses and their outreach practice. Public health nurses are well positioned to develop a relationship with the abused pregnant woman. However, Shepherd (1999) found that it may be difficult for the abused women to discuss problems in front of family members in her home. Although arranging to meet in another location was suggested, the abuser may prevent the woman from meeting. Shepherd found that the most significant finding in their study was that public health nurses were able to increase their interventions by providing information on resources for battered women. The role of public health care nurses is promising in providing better services to battered women during the perinatal period.

King & Ryan (1996) studied the role of midwives in assessing perinatal violence and recommended that midwives were also well positioned to take on this role. They caution that assessment is more about process than a single act, and that positive outcomes take longer to recognize than other nursing intervention outcomes.

The Attorney General's office stresses that we must avoid relying solely on checklists and tools. "Safety is not something that can be put on a form. It is something that has to be worked through with the woman herself" (Coombe, 1999: 7). Coombe cautions that front-line workers may find themselves in the position of having to make decisions for the woman, such as reporting abuse, rather than working in partnership with her. The collaboration between battered women's groups and the Attorney General's office has led to increased safety planning. It is recommended that this collaboration extend to health care services. Safety tracking tools and safety audits are now being developed within the battered women's movement (Coombe, 1999). It is recommended that these safety audits be incorporated into health care planning as well. Welch (1993) facilitated the development of community protocols in response to violence against women in relationships in Prince George. She used a collaborative, decision-making process with twenty-one organizations either in contact with, or providing services to battered women. The hospital and the Northern Interior Health Unit were not involved in this collaborative process. Their presence would have helped to develop that community network for health care providers working with pregnant and abused women.

Qualitative research studies are beginning to reveal the voices of battered women and what they identify as helpful (Gerbert, Abercrombie, Caspers, Love, & Bronstone, 1999). This study suggests that although women may not disclose the violence initially, they do appreciate being asked. They recommend that if a provider suspects abuse, they should assume that the patient is being battered without relying on disclosure. Most important, in their assessment, is to validate the woman's experiences by acknowledging abuse, and confirming the woman's value. They describe this as a dance of disclosure that involves both patient and physician. It was the validation of their situation and their worth, that for many women "planted a seed" which led to turning points in their relationships with abusers. Nevertheless, they caution that simply validating all patients "does not release the health care provider from paying attention to and intervening further with patients who display risk factors and signs of domestic violence" (Gerbert et al, 1999: 131). Assessing the patient's safety is still a critical part of practice.

The higher risk of abuse for pregnant teens and their reluctance to tell health care providers indicates that this is a significant area of concern. Service providers have suggested that there is a need for a separate safe resource for pregnant teens.

The scarcity of Canadian research on working with minority women and First Nations women must be addressed. Campbell (1996) describes cultural competence in working with abused women to include advocacy, minority representation in health care professions, and sensitivity to issues of ethnicity and violence. She also recommends that the woman be asked whether she would prefer a counsellor from her own culture, whenever possible. One possibility is to further explore the role of Hospital Aboriginal Liaison workers. First Nations women may hesitate to disclose abuse by their partners to the dominant culture, based on their awareness of the stigma and stereotypes already existing about violence in First Nations communities. More First Nations staff could be the key to better meet the needs of First Nations women.

The benefit of addressing the issue of violence against women from a public health perspective is significant (MacLeod & Kinnon, 1996). The Population Health Promotion Model looks at all interconnected factors, operating at the individual, community and societal levels which contribute to violence against women and the resulting effect on their health.

Many people feel that, as a society, we have been working for so long to stop the violence, and yet we have barely made a dent in the problem. Could our apparently limited progress be the product of narrow perspective? As a society, are we so entrenched in looking at the problem of preventing woman abuse in one way that we have lost the ability to problem solve effectively? (MacLeod, 1996: 12).
In this study, women indicated that they would prefer to use services that were not targeted at battered woman, but instead services which focused on building healthy families and communities. Therefore, the effort must become connecting more and more prevention work in the community. We must move from the negative state of violence against women to a positive vision: "A way of living defined not only by the absence of violence, but by a positive state of individual, family, community, institutional and societal health" (MacLeod, 1996:14). Her research stresses that community building means encouraging "people who do not see themselves as part of the problem or the solution, to get involved in the prevention of woman abuse" (Macleod & Kinnon, 1996: 40). Health care providers must be encouraged to see themselves as an integral part of the solution.

Conclusion

Violence against women during pregnancy is a troubling matter. It is a concern that requires a response at an interdisciplinary level, best achieved through a population health perspective, using the principles of women-centred health care. Such a fundamental shift however presents major dilemmas for medial and social service, and requires nurses and physicians to understand and address their own anxieties and the affects of these on their practice. Addressing the area of perinatal violence also requires that cultural issues and legal complications be further explored. The existing gaps in the research, including the roles of public health outreach nurses, midwives, cultural liaison workers, and battered women services working in coordination with medial services, indicates areas for further study to better meet the needs of women experiencing abuse in their lives.

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