30% of domestic violence (DV) begins during pregnancy and is most prevalent within the working and lower middle socio-economic classes. It is a major public health concern and abuse during pregnancy is of particular concern due to the health risks to both mother and child. It can cause physical and psychological harm to women, and lead to pregnancy complications and poor outcomes for babies.

Routine prenatal checkups could provide an opportunity to screen women and then refer them to an intervention programme. Findings suggest that screening programs in antenatal clinics generally increased rates of identification of women experiencing DV.  More recent studies provide evidence that universal screening is associated with improved pregnancy outcomes. A review by Sharps (2008) suggested that perinatal home-visiting programs are likely to reduce the incidence of physical abuse and improve pregnancy infant outcomes.

However there are currently no systematic reviews examining interventions specifically focusing on pregnant women. It is therefore not clear which interventions work best to ensure mothers safety during pregnancy and postpartum.

The objective of this review was to examine the effectiveness and safety of interventions in preventing or reducing domestic violence against pregnant women.

Method

The authors searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (June 2012), scanned bibliographies of published studies and contacted organisations that work in the area of DV for further trials. There were no language restrictions. Two review authors independently assessed trial quality (assessing for risk of bias using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions) and extracted data.

Inclusion criteria:

• RCTs including cluster-randomised trials and quasi-randomised controlled trials (e.g. where there was alternate allocation) investigating the effect of interventions in preventing or reducing domestic violence during pregnancy.
• Pregnant women of any age at any stage of pregnancy and their partners (if the intervention involved them)
• Any intervention, carried out in any setting, without screening or with screening (for those who screen positive) provided during pregnancy and aimed at reducing the number of episodes of DV.

Results

Nine trials with a total of 2,391 women were included, seven of which studied pregnant women who were at high risk of partner violence. The interventions examined in the studies varied considerably and ranged from single brief individualised consultation, case management and referral to a social care worker, and multiple therapy sessions during pregnancy and after birth.

The authors were unable to single out one intervention that worked better than the others. Due to a lack of consistency in the outcomes reported in the studies it was not possible to combine results from trials in meta-analysis so for most outcomes very few studies contributed data and results were predominantly based on findings from single studies.

There were no clinically significant differences between groups, most of the studies did not report on whether or not there had been any reduction in episodes of violence. Only one study reported findings for neonatal outcomes such as preterm delivery and birth weight and none of the studies reported important outcomes such as stillbirth, neonatal death, miscarriage, maternal deaths, antepartum haemorrhage and placental abruption.

• There was evidence from a single study that the total number of women reporting episodes of partner violence during pregnancy, and after birth was reduced for women receiving a psychological therapy intervention
• An intervention which aimed to improve women’s relationships with their partners and strengthen social networks slightly reduced psychological abuse and minor physical violence scores, but had no significant effect on severe physical violence scores
• There was no strong evidence that an educational video focusing on abusive relationships along with tailored case management was effective in reducing intimate partner abuse in the first three months postpartum
• Several trials examined whether women who received interventions were less likely to have depression after the birth of the baby, but results were inconsistent

Limitations

A serious problem in this review was the lack of consistency, the limited range of outcomes reported and the varied way that outcomes such as depression or experience of DV were measured.

Conclusion

This review clearly shows that there is a great need for more information from well-conducted trials before any particular interventional approach can be recommended. For such a major and potentially high risk health concern it is surprising how little evidence there currently is in this area. More trials are desperately needed!

References

Jahanfar S, Janssen PA, Howard LM, Dowswell T. Interventions for preventing or reducing domestic violence against pregnant women. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD009414. DOI: 10.1002/14651858.CD009414.pub2.

Sharps PW, Campbell J, Baty ML, Walker KS, Bair-Merritt MH. Current evidence on perinatal home visiting and intimate partner violence. Journal of Obstetric, Gynecologic, and Neonatal Nursing 2008;37(4):480-90; quiz 490-1.