Documenting domestic abuse

By Hermione Jackson, Digital Midwife Project Advisor on 09 December 2020

As a midwife, we are often faced with women who experience or are at risk of experiencing domestic abuse and violence. It can be challenging to even ask a woman about any current or past domestic abuse, but then to also know what to do with the information women disclose following this question can be challenging. Local services have their own systems for referral and support if that is what the woman wants, and it will undoubtably mean that there are many more agencies and member of the multi-disciplinary team (MDT) involved in the care going forward. But how do we as midwives document domestic abuse?

When I’m with a woman telling me about her experience, the first thing I focus on is documentation. It’s really important to ensure that I write down everything she says in her own words. There is a risk of seeming too official in a vulnerable moment when you’re keen to make notes, but the greater risk is not having enough information when completing referrals, or sharing with colleagues. We know that women don’t want to have to re-tell their story, particularly if it might be traumatising or difficult to talk about. Despite great continuity of carer, there will often be times care is provided by someone other than the named midwife.

Electronic records are transforming how we provide care for women who are victims of domestic abuse. I remember using coded messages on paper notes so it couldn’t be accessed by the woman’s family or perpetrator. The codes would signal to other professionals that the woman has told me of domestic abuse – but the codes could only take you so far. Whenever I picked up notes and saw a coded message, yes I was told the woman is at risk but I was missing the details, the history or even the information of the perpetrator who could be in the room with us. This often led to constructing scenarios to get the woman alone and ask her for more details, at the risk of adding to her trauma.

With electronic records we can include all the information needed to tailor our care for the woman and there is less risk of losing the key notes. The system also prompts you to ask about domestic abuse at booking and then again later in pregnancy. If I am unable to ask, the system would prompt the next maternity care provider. The information is stored safely within the medical record, but in a secret place where it is not visible unless absolutely necessary. We can also use a ‘partner present’ mode to hide information in case they can see the screen and the information is cleared in the personal record that she accesses via her smartphone.

Recent research by Sandi Dheensa (2020) discussed the lack of recent research into midwifery documentation of domestic abuse, and noted a lack of evidence around the use of electronic records. Her paper makes recommendations for midwives and health professionals to keep accurate records of domestic abuse and how that information should be safely shared.