3.2 Domestic Abuse Identification, Risk Assessment & Multi-Agency Referral

Domestic Abuse Identification, Risk Assessment & Multi-Agency Referral

Domestic abuse is a devastating public health epidemic and a profound violation of human rights. In the United Kingdom, pregnancy is a recognized catalyst and accelerant for domestic abuse: violence frequently begins, escalates in frequency, or increases in physical severity during gestation and the immediate postpartum period. The National Institute for Health and Care Excellence (NICE) and confidential maternal mortality inquiries (MBRRACE-UK) repeatedly identify domestic abuse as a direct and underlying cause of severe maternal morbidity, maternal suicide, and perinatal death.

Midwives are often the only healthcare professionals with whom an abused woman interacts outside her domestic setting. Establishing a safe, confidential environment for identification, risk stratification, and multi-agency referral is an essential clinical competency.

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The Domestic Abuse Act 2021: Statutory Definition & Scope

The Domestic Abuse Act 2021 created the first statutory definition of domestic abuse in UK law. Under the Act, behaviour of a person towards another person is defined as "domestic abuse" if both individuals are aged 16 or over, are personally connected to each other (such as intimate partners, former partners, or family members), and the behaviour is abusive.

The Act explicitly defines abusive behaviour as encompassing:

• Physical or Sexual Abuse: Direct bodily assaults, rape, reproductive coercion, or forced sexual contact.
• Violent or Threatening Behaviour: Direct physical intimidation, brandishing weapons, or threats of homicide or suicide.
• Psychological or Emotional Abuse: Belittling, systematic humiliation, gaslighting, destruction of personal property, or threats to harm children or pets.
• Controlling or Coercive Behaviour: An ongoing pattern of acts of intimidation, degradation, isolation, and control whereby the perpetrator subordinates the victim, deprives them of independent choice, and regulates their daily behaviour.
• Economic Abuse: Any behaviour that has a substantial adverse effect on an individual's ability to acquire, use, or maintain money or other property, or obtain goods or services. Examples in maternity include withholding travel funds to attend antenatal appointments, confiscating maternity allowance, controlling food purchases, or sabotaging employment.

Children as Victims in Their Own Right

Crucially, Section 3 of the Domestic Abuse Act 2021 establishes that a child under the age of 18 who sees, hears, or experiences the effects of domestic abuse, and is related to or has parental responsibility shared by either the victim or perpetrator, is formally recognized in law as a victim of domestic abuse in their own right. For midwives, any disclosure of domestic abuse involving an expectant mother who has existing children or is carrying an unborn infant immediately engages statutory child safeguarding protocols.

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Perinatal Epidemiology & Clinical Consequences

The epidemiology of domestic abuse during the perinatal period demonstrates stark clinical risks:

• Onset & Escalation: Up to 30% of domestic abuse begins during pregnancy, and in women with pre-existing abuse, 40% to 60% report an escalation in frequency and lethal intensity.
• Maternal Mortality: MBRRACE-UK reports consistently demonstrate that domestic abuse is heavily over-represented among women who die during pregnancy or within the first year following birth, particularly through maternal homicide and suicide.
• Direct Obstetric Complications: Blunt abdominal trauma inflicted by a perpetrator can cause direct placental abruption, uterine rupture, fetomaternal haemorrhage, premature rupture of membranes (PROM), and preterm labour.
• Indirect Perinatal Complications: Chronic psychological terror and neuroendocrine stress elevate circulating catecholamines and cortisol, contributing to intrauterine fetal growth restriction (FGR), low birth weight (under 2,500 grams), spontaneous miscarriage, and intrauterine fetal death (stillbirth).
• Maternal Mental Health: Profound elevation in rates of antenatal and postnatal depression, complex post-traumatic stress disorder (C-PTSD), panic disorders, self-harm, and substance dependency.

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The Universal Routine Enquiry Protocol

NICE guidance (PH50 and NG201) recommends that midwives conduct routine universal enquiry regarding domestic abuse, asking at booking or at the earliest opportunity when the woman is alone. This means asking every pregnant woman about domestic abuse, regardless of social status, demographic background, or the apparent absence of visible injuries.

Chronology of Routine Enquiry

Routine enquiry should not be treated as a single "tick-box" exercise at the booking appointment. Local policies typically repeat enquiry:

1. At the initial antenatal booking visit (ideally 10 to 12 weeks' gestation).
2. At regular intervals throughout routine antenatal visits (e.g. 28 weeks, 36 weeks).
3. On admission in labour or during inpatient antenatal triage attendance.
4. During inpatient postnatal ward stays and subsequent community postnatal home visits.

The Absolute Mandate of Privacy

Furthermore, strict clinical guidelines dictate that children over 24 months (2 years) of age must NOT be present in the consultation room during routine domestic abuse enquiry. Toddlers over 2 years have developing language comprehension and memory retention; they may repeat conversations or disclosures to the abusive partner upon returning home, placing the woman in mortal danger.

If a partner or relative refuses to leave the consultation room, the midwife must employ professional clinical tactics to secure privacy: requesting a routine physical examination, private urine sample, or chaperone-assisted procedure. If privacy cannot be achieved, the enquiry must be deferred to a future contact where privacy can be ensured, and the inability to assess in private must be noted in the confidential electronic record.

Independent Professional Interpreting

Where an expectant mother does not speak English fluently, midwives must use an accredited, independent professional telephone or face-to-face interpreter. Under NO circumstances should a partner, relative, friend, or community member be used to interpret safeguarding questions. Perpetrators routinely volunteer to interpret to manipulate translation, conceal abuse, and maintain total coercive control over the victim.

Standard Framing & Enquiring Language

Enquiry should be introduced with normalizing, supportive framing:

• "Because relationship stress and abuse are very common and can affect the health of both you and your baby, we ask all women who attend maternity care these routine questions."
• "Does anyone at home make you feel afraid, humiliate you, or control where you go and who you speak to?"
• "Has your partner or anyone close to you ever pushed, slapped, kicked, choked, or hurt you physically?"
• "Does your partner control your money, prevent you from buying essentials, or stop you attending appointments?"
• "Do you feel safe returning home today?"

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Recognizing Clinical & Behavioural Red Flags

Abused women are frequently trapped by fear, shame, or coercive threats, preventing spontaneous disclosure. Midwives must recognize covert clinical and behavioural indicators:

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Immediate Safety Planning Following Disclosure

When a woman discloses domestic abuse, the midwife's initial response is clinically critical. The midwife must validate the disclosure using empathetic, non-judgmental language:

• "Thank you for telling me. I believe you. You and your baby do not deserve to be treated this way. We are here to support you safely."

Immediate Risk Assessment: Assessing Imminent Threat

The midwife must immediately establish whether the woman is in acute danger:

• Is it safe for you to return home from the clinic today?
• Where is the perpetrator now? Does he know you are here?
• Has he made direct threats to kill you, harm your children, or harm the baby?
• Has he ever choked, strangled, or smothered you?
• Are there weapons in the home?

If the woman is at immediate risk of severe violence or homicide, she must NOT be discharged home. The midwife must coordinate with hospital security, the police (via 999), and emergency domestic abuse refuge services from the clinic setting.

Creating a Practical Emergency Safety Plan

If the woman chooses to return home, a discreet safety plan must be co-produced:

1. Emergency Grab Bag: Hidden with a trusted friend, family member, or neighbour, containing essential birth certificates, passports, immigration paperwork, prescription medications, duplicate keys, emergency cash, and baby supplies.
2. Emergency Code Words: Agreed phrases established with trusted neighbours, family, or older children to trigger an immediate call to 999.
3. Safe Room Identification: Identifying an area of the home with accessible exit doors and avoiding rooms with hard surfaces or potential weapons (such as kitchens and bathrooms).
4. Emergency Contact Numbers: Memorizing or securely concealing the free, 24/7 National Domestic Abuse Helpline (0808 2000 247) and local domestic abuse outreach contacts.

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DASH Risk Assessment & MARAC Multi-Agency Referral

To standardize risk assessment across police, health, and social services, UK agencies use the DASH (Domestic Abuse, Stalking and Harassment and Honour-Based Violence) Risk Identification Checklist.

The DASH Risk Identification Checklist

The DASH-RIC is an evidence-based tool containing 24 targeted questions assessing known lethal risk factors. Critical high-lethality markers include:

• Non-fatal Strangulation / Suffocation: Increases the statistical odds of subsequent intimate partner homicide seven-fold.
• Pregnancy / New Baby: Heightens vulnerability and jealousy.
• Threats to Kill / Suicide: Perpetrator threats of murder or murder-suicide.
• Use of Weapons: Brandishing knives, firearms, or household objects.
• Severe Controlling / Coercive Behaviour: Total isolation of the victim.
• Escalation: Marked increase in frequency, severity, or irrationality of violence.
• Separation: The period immediately following a victim leaving or attempting to leave the perpetrator carries the single highest risk of lethal violence.

Multi-Agency Risk Assessment Conference (MARAC)

A MARAC is a regular local multi-agency meeting where statutory and voluntary agencies meet to share information on the highest-risk domestic abuse cases. Represented agencies include the police, Independent Domestic Violence Advisors (IDVAs), Children's Social Care, housing, mental health, substance misuse services, probation, and health (maternity).

Cases meet the threshold for an urgent MARAC referral if:

1. DASH Score Threshold: The DASH assessment identifies 14 or more affirmative 'yes' responses.
2. Professional Judgment: A midwife, police officer, or IDVA assesses that despite a lower numerical score, the severity of coercive control, strangulation, or threats poses a grave risk of serious injury or homicide.
3. Escalation / Repeat Victimization: Rapidly increasing frequency of police callouts or hospital triage attendances within the past 12 months.

The Role of the IDVA

An Independent Domestic Violence Advisor (IDVA) is a specialized, independent crisis case worker who represents the voice of high-risk victims. IDVAs coordinate safety planning, advocate for emergency social housing relocation, provide emotional support, and assist women in obtaining emergency civil protective court injunctions, such as Non-Molestation Orders, Occupation Orders, or Domestic Abuse Protection Orders (DAPO).

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Safe Documentation Protocols

Midwives must adhere to strict documentation rules to prevent exposing victims to catastrophic retaliatory violence.

Perpetrators of domestic abuse routinely scrutinize maternal hand-held pregnancy records. Discovering a documented disclosure, a domestic violence brochure, or a recorded social services referral frequently triggers lethal retaliatory assault. All domestic abuse documentation must be entered exclusively into the restricted, confidential safeguarding module of the hospital's internal electronic health record (EHR), fully shielded from patient-facing portals.