DOI: 10.1111/tog.
12374
The Obstetrician & Gynaecologist
http://onlinetog.org
Domestic violence: a neglected epidemic in obstetrics and
gynaecology training
a b
Chantal Cox-George BSc(Hons), Joanne Moffatt
a
Medical Student, Department of Obstetrics & Gynaecology, University of Bristol Academy, Swindon, Wiltshire SN6 6BB, UK
b
Clinical Teaching Fellow, Department of Obstetrics & Gynaecology, University of Bristol Academy, Swindon, Wiltshire SN6 6BB, UK
c
Consultant and Academy Dean, University of Bristol Academy, Swindon, Wiltshire SN6 6BB, UK
*Correspondence: Kevin Jones. Email: kevin.jones@gwh.nhs.uk
Accepted on 4 September 2016
Key content
 There needs to be improved understanding of issues around
domestic violence, particularly among obstetrics and
gynaecology clinicians.
 Domestic violence occurring during pregnancy has negative
consequences on morbidity and mortality for both the mother and
the unborn child.
 Up to 30% of women present as victims of domestic violence in
pregnancy; therefore, it is of the utmost importance that teaching
on this topic is introduced into the national obstetrics and
gynaecology curriculum.
Please cite this paper as: Cox-George C, Moffatt J, Jones K. Domestic violence: a neglected epidemic in obstetrics and gynaecology training. The Obstetrician &
Gynaecologist 2017; DOI:10.1111/tog.12374.
Introduction
In the UK, 7.1% of women report having experienced some
form of domestic violence1 and the majority of victims of
domestic violence will see five professionals, on average,
before they receive effective support.2 Mothers and Babies:
Reducing Risk through Audits and Confidential Enquiries
across the UK (MBRRACE-UK) estimated that 30% of cases
of domestic violence start or escalate in pregnancy.3
Domestic violence occurring during pregnancy has negative
consequences on morbidity and mortality for both the
mother and the unborn child, with a fetal mortality rate of
approximately 16 per 1000 affected pregnancies.1 A key
recommendation of the 2014 National Institute for Health
and Care Excellence (NICE) guidance on domestic violence is
that ‘education is part of the undergraduate curriculum and
CPD’ for those who will encounter women at risk.4
Less than 200 years ago, a husband was legally allowed to
physically abuse his wife, provided ‘the stick he used was
smaller in diameter than his thumb’.5 Today, the government
and professionals in health and social care recognise and
appreciate the unacceptable public health issue that is domestic
ª 2017 Royal College of Obstetricians and Gynaecologists
Review
c,
BSc(Hons) MBBS, Kevin Jones BSc(Hons) MBChB FRCOG MSc MD *
 The current provision of undergraduate and post-qualification
training in domestic violence in obstetrics and gynaecology falls
below the standards set by other professional groups.
Learning objectives
 To understand the impact of domestic violence presenting in
obstetrics and gynaecology.
 To review the undergraduate obstetrics and gynaecology
curriculum and CPD in domestic violence.
 To consider opportunities for multidisciplinary training about
domestic violence.
Keywords: continuing professional development / domestic
violence / national standards / training
violence. The Home Office defines domestic violence as ‘any
incident or pattern of incidents of controlling, coercive,
threatening behaviour, violence or abuse between those aged
16 or over who are, or have been, intimate partners or family
members regardless of gender or sexuality’.6 This definition
includes psychological, physical, sexual, financial, emotional
and other forms of abuse such as honour-based violence.7 Data
produced by the Office for National Statistics from the 2012/13
Crime Survey for England and Wales4 showed that 30% of
women and 16.3% of men between the ages of 16 and 59 years
reported that they had experienced at least one form of
domestic violence during their lifetime, which equates to
approximately 4.9 million women and 2.7 million men in total.
The same report estimated that 7.1% of all women are affected
by domestic violence per year.1 It is, however, extremely
difficult to quantify the extent of the problem because not all
cases are reported. Victims may be reluctant to disclose
domestic violence because of fear that they will not be believed,
fear of the consequences or they may not identify their
situation as abuse.8 Healthcare professionals may lack
experience or awareness of domestic violence or fail to
enquire routinely about domestic violence.
1
 Domestic violence: a neglected epidemic
Domestic violence is an important public health issue but
also an issue that many members of the medical profession
feel uncomfortable or inadequately informed to manage.
Healthcare professionals have cited reasons including a lack
of confidence in both enquiring about and dealing with
domestic violence,9 underpinning their reluctance to ask
patients about potential domestic abuse. Universal screening
for domestic violence was thought to provide some remedy
to this problem and is advocated by healthcare facilities in the
USA.10 Current NICE guidance4 recommends that staff in
contact with women during the antenatal and postnatal
period ask about domestic violence as a routine part of care,
and safeguarding of vulnerable adults and children is often a
component of NHS trust mandatory training. Evidence
supports selective screening for domestic violence in
‘high-risk’ patient populations, such as those attending
gynaecology and HIV outpatient clinics,11 although as of
yet no link has been made between universal screening and
the long-term benefit demonstrated.12 Other innovative
approaches include the placement of posters behind toilet
doors in routine antenatal clinics telling women to place a
blue sticker on their urine sample bottle if they wish to talk to
a midwife about domestic abuse without their partner being
present. The midwife then ensures that he or she sees the
patient alone at some point during the consultation.
This article aims to put forward a case for incorporating
teaching on domestic violence into both the national
undergraduate and postgraduate obstetrics and gynaecology
curriculums. The authors present the argument that the
current provision of undergraduate and postgraduate
training in domestic violence in obstetrics and gynaecology
falls below the standards set by other professional groups.
The article reviews the literature on domestic violence,
specifically focusing on the impact of domestic violence
presenting in obstetrics and gynaecology. The undergraduate
obstetrics and gynaecology curriculum and continuing
professional development (CPD) opportunities in NHS
institutions are also reviewed, and suggestions made for
multidisciplinary training opportunities.
The impact of domestic violence: are we
missing an epidemic?
The Department of Health estimates that women experience
35 episodes of domestic violence before seeking help.8
Victims of domestic violence may present to emergency
departments, in general practice, psychiatry or obstetrics and
gynaecology, but 85% of victims see five professionals, on
average, before they receive effective support.3 The
MBRRACE-UK report estimates that one-third of
domestic violence starts (or escalates) in pregnancy.2 It is
recognised that women who experience domestic violence in
pregnancy have increased risk of adverse pregnancy
2 ª 2017 Royal College of Obstetricians and Gynaecologists
outcomes and domestic violence in pregnancy is associated
with a fetal mortality rate of approximately 16 per 1000
affected pregnancies.1 These complications include
depression, preterm delivery, low birthweight, spontaneous
miscarriage, intrauterine death, and perinatal maternal and
infant death.13 These complications are similar to those
associated with pre-eclampsia and gestational diabetes –
important medical conditions that undergraduate and
postgraduate obstetrics and gynaecology trainees are
repeatedly reminded not to miss. The incidence of these
conditions in the UK is 0.05%,14 and 2–5%,15 respectively,
compared with an estimated incidence of domestic violence
during pregnancy of 4–12%.7 This should not detract from
teaching on pre-eclampsia and gestational diabetes, but
raises the question as to why we spend so much of our
scarce resources on medical issues that are less common
than domestic violence and which have a lower
mortality rate.
Domestic violence education
While the Royal College of Obstetricians and Gynaecologists
(RCOG) supported the 2014 guidance produced by NICE on
domestic violence and abuse,16 a key recommendation
included in the guidance has yet to be addressed. NICE
recommended that domestic violence be ‘part of the
undergraduate or pre-qualifying curriculum, and part of
the continuing professional development’4 for those working
with these patients. Consequently, safeguarding of vulnerable
adults and children is often a component of NHS trust
mandatory training and required at Level 3 for all consultants
and midwives.
The British Medical Association has highlighted the
absence of any direct mention of domestic abuse or
domestic violence within the General Medical Council
recommendations for undergraduate medical education,7
although some universities have included domestic violence
in their curriculums. For example, the University of Bristol
Medical School includes domestic violence in its primary care
curriculum, expecting students to be able to identify patients
who may be at risk of intimate partner violence and have
strategies to help them.
Despite the significant number of cases of domestic
violence that begin in pregnancy and the effects of abuse
on both mothers and their unborn children, it is surprising
that there is currently no requirement for teaching on
domestic and intimate partner violence in the RCOG
undergraduate curriculum.17 The RCOG emphasised its
commitment to improving the understanding and
management of women experiencing domestic violence as
part of the 2015 International Women’s Day.18 Despite this,
and while several statements in support of continuing
research into domestic violence exist, domestic violence

remains unaddressed in national obstetrics and gynaecology
undergraduate education.
The RCOG has produced an informal curriculum for
foundation doctors, stating that foundation doctors should
be ‘aware of domestic violence affecting women’,19 but
arguably, this is inadequate. Additionally, there is no specific
reference to domestic violence in the RCOG postgraduate
curriculum for obstetrics and gynaecology trainees. Despite
this, domestic violence has been a part of the Managing
Obstetric Emergencies and Trauma (MOET) course and also
a question in the MRCOG part 2 examination.
By contrast, general practitioners (GPs) appear to be well
aware of the far-reaching consequences of this issue. The
Royal College of General Practitioners has produced clear
and extensive guidance for GPs on how to care for women
who have been subject to domestic violence and who present
in the community and refers to domestic violence in its
women’s health curriculum.20,21 Colleagues from the Royal
College of Emergency Medicine and the Royal College of
Psychiatrists have also produced guidance on the
management of domestic violence in their departments.22,23
The UK is lagging behind other countries in postgraduate
education on domestic violence in obstetrics and
gynaecology. The American Congress of Obstetricians and
Gynecologists has produced guidance for healthcare
providers who may come into contact with domestic
violence.24 The Academy on Violence and Abuse provides a
list of relevant competencies and guidance for the
accreditation organisations that provide training.25
Similarly, the Society of Obstetricians and Gynaecologists
of Canada advises a robust system of multidisciplinary
training in combination with guidelines focusing on
domestic violence.26 It also provides a number of screening
tools for use in various settings. The Royal Australian and
New Zealand College of Obstetricians and Gynaecologists
refers to domestic violence in its curriculum requiring
trainees to ‘assess and manage sexual and domestic
violence’ incorporating the recognition and appropriate
response to domestic violence.27 Furthermore, it provides
an e-learning programme for both specialist trainees and GPs
focusing on sexual assault.28
NICE recommends that training on domestic violence be
provided to all professionals who care for at-risk patient
groups. The level of training recommended corresponds to
the role of the healthcare practitioner; for example,
healthcare assistants are required to obtain ‘level 1’ training
whereas safeguarding leads require ‘level 4’ training.29
Despite this, to the authors’ knowledge there is no
requirement to include domestic violence in mandatory
training for healthcare professionals, apart from the primary
care curriculum which refers to domestic violence in the
‘women’s health’ part of their training. Some trusts do offer
training in this area. Refuge, a charity supporting women and
ª 2017 Royal College of Obstetricians and Gynaecologists
Cox-George et al.
children who are victims of domestic violence, has pioneered
the Independent Domestic Violence Advocacy programme.
Independent Domestic Violence Advocates are specially
trained to provide support to victims of domestic violence
and also provide expert training to midwives across the
country.30 Additionally, Women’s Aid, a national charity
supporting victims of domestic violence, offers a number of
training courses for healthcare professionals, which can be
counted towards CPD.31
Multidisciplinary opportunities –
simulation
Simulation is quickly becoming a mainstay of medical
education in terms of teaching clinical skills, emergency drills
and communication skills. It also has a role in the assessment of
students.32 In both undergraduate and postgraduate settings,
teaching on communication in difficult circumstances is
taught via role-play or simulation and these tools could be
used in domestic violence training. In Israel, Shefet et al.33
developed a ‘national experiential domestic violence training
program’ in order to improve physicians’ knowledge, skills and
detection rates of domestic violence. This took the form of an
8-hour workshop led by a physician and social worker
specialising in domestic violence. Participants were filmed
while they encountered several simulated domestic violence
scenarios. Watching back segments of the interaction and
receiving feedback from the actors and workshop leaders
facilitated reflection and constructive criticism on participants’
communication skills. The workshop leaders also ensured that
the important educational messages of the session were elicited
or discussed. The programme proved effective in improving
‘self-perceived preparedness and competences’, including
physicians’ knowledge of domestic violence, detection and
referral rates.33
The aforementioned example of simulation teaching on
domestic violence did not include undergraduate medical
students. However, this omission does not imply that a
similar teaching tool would not also be effective before
qualification. In contrast to a more traditional, classroom-
based and didactic style of teaching, simulation teaching –
where participants practise tasks in real-life circumstances –
has proved highly effective in linking theory to practice at
both undergraduate and postgraduate level. Examples of
successful simulation during postgraduate training include
teaching a wide range of clinical skills, laparoscopic surgical
training and managing rare but potentially fatal obstetric
emergencies, for example, shoulder dystocia, postpartum
haemorrhage and eclampsia.34 The RCOG runs CPD courses
such as MOET and basic surgical skills courses nationally and
internationally, so developing similar teaching material for
domestic violence might be an extension of this
CPD programme.
3
 Domestic violence: a neglected epidemic
The most important feature of simulation is the provision
of educational feedback,35 also known as debriefing. Fanning
and Gaba36 stress the importance of the debriefing process as
one in which ‘students feel valued, respected, and free to learn
in a dignified environment’. There is also a need to consider
which individual(s) lead the debrief. Options may include
trained health and social care professionals, clinical teaching
fellows, trained charity workers and victims of domestic
violence. Simulation is unique in that it brings ethical issues
and safeguarding concerns to life and possibly triggers certain
emotions in the participants involved in teaching. For this
reason, the debrief must be a ‘supportive climate’,37 in which
the differing needs and reactions of the simulation participants
are both appreciated and appropriately responded to. This
applies in all types of simulation but may be particularly
important in domestic violence teaching because of the
intensely private and sensitive nature of the topic.
Statistically, there is a chance that one or more of the
participants has witnessed, has personal experience (past or
present) or knows of someone who has experienced domestic
abuse. The simulation leaders must be aware of this before,
during and after the simulation session and make every effort
to address any pastoral needs revealed by the teaching session.
Conclusion
This article has provided evidence that shows that domestic
violence is a serious health and social care issue that is being
neglected in today’s undergraduate medical education in the
UK, particularly by the RCOG. This is unacceptable because
of the negative consequences that domestic violence has on
both women and their unborn children. The statistics suggest
that domestic violence may present in a variety of settings but
because 30% of women present as victims of domestic
violence in pregnancy, the authors argue that it is of the
utmost importance that teaching on this topic is introduced
into the national obstetrics and gynaecology curriculum.
Because of the intimate and sensitive nature of domestic
violence, the authors have suggested that simulation teaching
is likely to be the best way to do this because it provides
undergraduate and postgraduate students with a situation
that most closely resembles a real-life clinical scenario. It also
has the potential to be combined with training in other
healthcare professions, such as midwifery, at the same time –
encouraging a multidisciplinary approach from the outset.
An additional benefit of simulation teaching is that it allows
for constructive feedback and an opportunity to debrief in a
protected environment.
Contribution to authorship
KJ instigated and edited the article. CCG researched and
wrote the article; JM wrote and edited the article. All authors
approved the final version.
4 ª 2017 Royal College of Obstetricians and Gynaecologists
Disclosure of interests
The authors of this article have no conflict of interest
to disclose.
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