Case Study: Intimate Partner Violence

Sarah is having her first baby. She’s in her early 20s, and recently married: her parents and in-laws spent a lot of money on a lavish church wedding and honeymoon. On her wedding day, Sarah paused on her way into the church, her arm linked in her father’s, feeling a dread in her gut that she was making the wrong decision in marrying this man but currently saw no way out; few narratives had shown her a life other than marriage to a man and children.

Several years earlier, after high school, Sarah got a job at a factory. There she noticed a young man paying particular attention to her, someone known around the factory as a nice guy, and she decided to go on a date with him, not having had any previous romantic encounters. The date started off well, and after dinner and a movie, he offered to drive her home. Instead of taking her straight there, however, he took Sarah to a secluded area and demanded she have sex with him. When she said no, he did anyway, forcibly. After a derogatory comment about her loss of virginity, he dropped her off at her parent’s home. Feeling overwhelmingly ashamed and shocked, Sarah took a bath and contemplated taking a bottle of pills. The next day, she told her mother what happened, and her mother, fearing her daughter be labelled as promiscuous, urged that Sarah marry him and make the best of the situation.

Caring deeply about her family’s approval, Sarah got married despite a sense of dread. She became pregnant shortly after her wedding, and her husband also began hitting her around this time. Feeling an overwhelming instinct to protect her child, Sarah did everything in her power to placate her husband, including enabling his drinking to the point he would pass out and would no longer be a threat. Throughout her pregnancy, her husband became increasingly violent, though he avoided causing visible evidence, and became obsessed with the possibility that this wasn’t his child, and that Sarah had cheated on him.

Of course, you don’t know any of this when you meet Sarah for the first time. What you do notice is that she has a slight bruise around her wrist, and her husband hasn’t come to any appointments: a fact that Sarah defends with vigour. You begin to suspect she might not be safe, and are also concerned for what may transpire when the baby comes.

Question 1

What are some of your options in seeing Sarah through her pregnancy and labour with care?

a) During one of your appointments, you could confront Sarah directly and tell her she needs to leave her husband.
b) You could call the police, or the local child-and-family services (at this point, there are no children involved).
c) You could build trust with Sarah for a few appointments by supporting her and being positive about her.
d) Be indirect in offering resources and support services

While you may feel a sense of urgency in assuring Sarah and her child’s safety, answers a) and b) have the potential to make matters worse for her. Here are a few things to keep in mind when caring for a client who appears to be in a situation of partner violence:

1. Clients with abusive partners may experience the most abuse during the pregnancy and postpartum periods (Moore 1999);
   Expectant fatherhood can arouse feelings of fear and insecurity in the father-to-be about his own role in parenting, especially if he faced abuse from his own father. These feelings can manifest through control and abuse of partners. In Sarah’s case, her husband was abused by his father.
2. Often, abusive partners maintain control through emotional and psychological violence, making it less visible.
   Sarah’s husband, for instance, has repeated told her she is “ruined” for any other man, and that he is the only one who will “put up” with her. Because of this, Sarah feels the unbearable tension of being afraid of leaving, and ashamed that she stays.
3. Direct confrontation – saying “you need to leave right now,” for instance – can potentially increase danger.
   Sometimes criticism of abusive partners can lead to the client becoming defensive of their partner and their situation, particularly if the direction makes them feel ashamed of staying in a situation they know is dangerous, but can’t yet leave.
4. Depending on the situation, some abusers exert control by requiring their partners to report every interaction with every person they encounter.
   For instance, after a midwifery appointment, the client may feel they need to report what was discussed, and if the midwife recommended leaving, this may lead to anger by the abusive partner that puts the client in significant danger. In addition, further controls may be put on the client (like not being able to go out at all), narrowing their scope of support.
5. Leaving a violent relationship is not simple, and a safety plan needs to be in place before someone may decide leaving is better than staying (Macy et al. 2009).
   These plans can include securing a safe place to go, like a relative’s house or shelter; keeping important documents in a hidden location; memorizing emergency numbers, and assuring financial security. Sarah’s husband controls their bank accounts, but she has been reserving small amounts of cash when he asks her to take out money for his trips to the bar.
6. Violence often leads to chronic health problems, which can impede the ability of carry out a safety plan. (Macy et al. 2009)
   During pregnancy, the development of chronic conditions due to physical violence increases stress, creates delays in seeking care, and can lead to poor nutrition, and substance abuse to cope (Moore 1999).
7. Those in situations of violence are not passive victims, but are often weighing their options carefully:
   Sarah, for example, knows she shouldn’t be ‘letting’ this happen to her, but is anxious about her ability to care for a new baby on her own, her financial well-being if she leaves, and her family’s insistence that divorce is a sin. These may seem to be trivial, but for Sarah, these are her very real struggles, and it is because of this that many prefer the term survivor over victim.

Question 2

What can you do as a midwife?

1. Screening for violence should be universal; that is, all clients can be given information on resources and safety – this also needs to be done apart from partner
2. Providing information for leaving an abusive relationship (how to develop a safety plan, signs of violence, expectations of what a healthy relationship looks like, and resources available (like shelters, financial and legal aid)) can be done anonymously through posters in offices, bathrooms, exam rooms, and brochures given directly. Even providing ‘safety cards’ throughout the clinic that are discreet and carry useful information about resources.
3. When leaving a violent situation, many clients need the support of a variety of services. Midwives can foster a sense of community practice and advocacy by familiarizing themselves with the services available – counselling, legal and financial aid, medical services beyond birth care, housing, etc.
4. Ultimately, those in violent situations need support in a non-judgemental setting: you should be there to offer a relationship built on trust and support, to build the client up and emphasize the positive aspects of what they are doing in relation to their pregnancy, birth, and care of their infant. In this way, you can say in a context of trust, “when you’re ready, here are some resources and supports that you can access in order to help you leave.”