DOI: 10.1111/1471-0528.

12609 Sexual health

www.bjog.org

A comparative study of the prevalence of

domestic violence in women requesting a
termination of pregnancy and those attending
the antenatal clinic
TT Wokoma,a,b M Jampala,c H Bexhell,b K Guthrie,a,b S Lindowb
a
Sexual and Reproductive Healthcare, Conifer at Wilberforce Centre, Hull, UK b Department of Obstetrics and Gynaecology, Hull Royal
Infirmary, Hull and East Yorkshire NHS Trust, Hull, UK c Lupset Surgery, Wakefield, West Yorkshire, UK
Correspondence: Dr TT Wokoma, Sexual and Reproductive Healthcare, Conifer at Wilberforce Centre, 6–10 Story Street, Hull, HU1 3SA, UK.
Email tonye.wokoma@nhs.net

Accepted 19 November 2013. Published Online 22 January 2014.

Objective To compare the prevalence of domestic violence (DV)
in women requesting antenatal care (ANC) and termination of
pregnancy (TOP) in North East England.
Design This was a cross-sectional comparative prevalence study
using self-administered questionnaires, with women selected as
opportunistic samples over a concurrent period.
Setting The participants were screened anonymously
confidentially in the ANC and TOP clinics.
Sample Pregnant women in the first trimester requesting a TOP
or ANC.
Methods The participants were screened for a history of DV using
a modified version of the Abuse Assessment Screening tool.
Main outcome measures Prevalence of DV between ANC and
TOP populations, and any differences in the characteristics of the
women, such as age, level of education, or marital status. We
aimed to determine the reasons for requesting a TOP.
Results There were 507 respondents, with 233 attending ANC and
274 requesting a TOP. Of the ANC population, 219 completed the
questionnaire. In the TOP population, all the questionnaires were
fully or partially completed. Women requesting a TOP were six
times as likely to suffer physical abuse in the current relationship
(5.8 versus 0.9%; v2 = 10.2 (2); P < 0.05), and were five times as
likely to suffer emotional abuse (9.9 versus 1.8%; v2 = 13.6 (2);
and P < 0.0001), than those attending ANC. Of the 274 women
requesting a TOP, only ten mentioned DV as a contributing
factor.
Conclusions There is a higher prevalence of DV in the TOP
population than in the ANC population, but very few women
stated that DV influenced their request for a TOP.
Keywords Abortion, antenatal care, domestic violence,
gender-based violence, pregnancy, termination of pregnancy.

Please cite this paper as: Wokoma TT, Jampala M, Bexhell H, Guthrie K, Lindow S. A comparative study of the prevalence of domestic violence in women
requesting a termination of pregnancy and those attending the antenatal clinic. BJOG 2014;121:627–633.

Almost half of all adult women in England and Wales

Introduction
Domestic violence (DV) and abuse is defined as ‘Any inci-
dent or pattern of incidents of controlling, coercive or
threatening behaviour, violence or abuse (psychological,
physical, sexual, financial, emotional) between those aged
16 or over who are or have been intimate partners or fam-
ily members regardless of gender or sexuality’.1 There was
an estimated 1.2 million female victims of DV,2 and the
direct and indirect cost of DV alone in the UK is estimated
to be £23 billion.3
have experienced violence in one form.3 It has been esti-
mated that the lifetime prevalence of DV against women in
the general UK population ranges from 13 to 31%, and that
it is widespread amongst pregnant women.4 Domestic vio-
lence is a matter of importance because of the many obstet-
ric complications and psychological effects that may arise as
a consequence.5 It is a major risk factor for psychiatric dis-
orders, chronic physical conditions and substance abuse.6
A study of pregnant women in antenatal care (ANC) in
East London showed 15% were found to be experiencing

ª 2014 Royal College of Obstetricians and Gynaecologists 627

 Wokoma et al.
DV, and that for 40% of these women DV began during
pregnancy.7 Women in ANC with a history of DV, and
who have experienced DV in the last year, are likely to be
current victims of DV.5 In a study of 475 pregnant women
in North England, the prevalence of DV was quoted as
17%, with the highest rates/frequency in women aged 26–
30 years. In that study, 10% of the study population was
coerced into sexual activity by their partners.8 Another
cross-sectional study showed abuse in pregnancy to be sig-
nificantly associated with an increased risk of perinatal
death and, among live births, of preterm low birthweight
and term low birthweight. A greater abuse frequency was
associated with increased risk.9
Few studies have specifically focused on comparing the
prevalence in women in ANC with those requesting a ter-
mination of pregnancy (TOP), although there are several
studies that have investigated the prevalence of DV in preg-
nant women.6,10–12 This present study, therefore, compares
the prevalence of DV in women requesting antenatal or
abortion care in the Hull and East Riding area to assess dif-
ferences in their characteristics, such as age, level of educa-
tion, marital status, and ethnicity, and to find out their
reasons for the request for a TOP.
Methods
The study was conducted as a self-administered anonymous
questionnaire survey of unaccompanied pregnant women
attending the antenatal clinic or the TOP pre-assessment
clinic in the first trimester of pregnancy at the Hull and
East Riding NHS Trust in North East England. A conve-
nience sample of all pregnant women attending the ANC
and TOP clinics between January 2011 and November 2012
was selected. Exclusion criteria included young women
below the age of 16 years, who are deemed to be minors,
as the recognised definition of DV excludes them. Women
not fluent in the English language were also excluded. We
considered that the presence of an interpreter would be
necessary for the clarification of details, and this was
judged to be inappropriate because confidentiality and
anonymity would be compromised.
For the purpose of the study, we enlisted the services of
the hospital midwives, nurses, and healthcare assistants to
recruit the participants and to hand out questionnaires. A
brief discussion of the objectives of the study was under-
taken with each volunteer healthcare staff member. Senior
nursing staff members were informed and consent was
obtained for the study to be conducted during routine
duties and working hours. The participants were screened
using a modified version of the Abuse Assessment Screen-
ing tool to suit the purpose of the research.13 Screening
took place in a regular clinic room that was identified for
the purpose of the study. A pre-study assessment of the
628
room for privacy and confidentiality was undertaken by a
member of the research team. A secure box with an aper-
ture in the top cover was also provided for forms to be
confidentially placed after completion. The women were
invited unaccompanied into the room to measure their
weight, height, and to record their blood pressure. These
are measurements that are routinely checked during regular
clinic visits as part of a general medical assessment. Upon
entering the room a brief explanation of the study objec-
tives was provided by the clinician responsible for vital
signs assessment, and thereafter the patient was invited to
participate in the study.
Each patient was then offered a laminated Patient Infor-
mation Leaflet that expanded on and reiterated the aims
and objectives of the study. The initial section of the
questionnaire reaffirms the invitation to the study and
assures the patient regarding anonymity and confidential-
ity. Women who attended the clinic with friends, spouses,
or relatives were invited into a private room for blood
pressure measurement and were encouraged to attend
alone. The invitation for lone consultation was offered only
once. Repeated attempts to obtain a lone consultation were
avoided, as we believe that this might imply coercion.
Women who declined the lone invitation were not invited
to participate. Accompanied women were not included in
the study as the presence of a third party may limit full
disclosure, invalidate anonymity, and may have untoward
consequences, such as feelings of embarrassment, shame,
or humiliation. Also, if the accompanying individual was
the DV perpetrator, the knowledge of disclosure may also
lead to a potential escalation and retaliation against the
victim.
The women were allowed as much time as required to
complete the questionnaire. They were then requested to
place the completed (or uncompleted) form in a sealed
box, which was emptied at the end of each day. The ano-
nymity of data was achieved by the lack of personal identi-
fiable characteristics on the questionnaire, and women were
not under pressure to participate in the study. In addition,
the women were assured full confidentiality, with no one
being made aware of their decision to participate in the
study or even the invitation to participate. The patient
information leaflet explained that the information obtained
from the study would help to improve services offered to
women. Signed consent was not requested, as this was
thought to discourage potential participants from taking
part in the study; therefore, only verbal consent was
sought.
The investigators were aware of the possibility that the
questionnaires, about a sensitive or embarrassing issue,
could provoke emotional distress in study participants,
especially at a difficult time. However, previous studies in
our unit have shown that our indigenous population did
ª 2014 Royal College of Obstetricians and Gynaecologists

not appear to have demonstrated these tendencies, and did
not report any distress in filling self-administered, confi-
dential questionnaires on the topic of DV. Helpline num-
bers were printed at the bottom of each questionnaire, and
advice and support were made available to the participants
as required.
There were separate questionnaires for each clinic group,
and they comprised closed questions to ensure that the
participants did not find it overly tasking to complete. The
questions on both questionnaires were the same, but the
TOP questionnaire contained additional questions on
whether the partner was aware of the TOP request, any
previous TOP, and reason(s) for the TOP request.
For both groups, the first section was for the singular
purpose of collecting demographic data, which included
information about their educational background, number
of children, and relationship status. Another section
obtained data about whether women had or were currently
experiencing physical or emotional DV in a relationship.
The next section of the questionnaire sought to identify the
perpetuators in the event of an affirmative answer for the
question on whether or not the women experienced DV. In
addition, the frequency of occurrence of DV was sought.
The second section of the questionnaire for both groups
was meant for those who responded in the affirmative, and
comprised questions on the perpetrators as well as the nat-
ure and extent of the abuse. A series of acts of abuse were
listed, encompassing a range of actions of differing severity.
These included physical and non-physical acts of violence,
such as slapping, pushing and shoving, being beaten up,
severe bruising, grievous bodily harm, burns, broken bones,
head injuries, internal organ damage, permanent injuries
and disabilities, and use of weapons, as well as verbal, emo-
tional, and psychological violence. Further questions
requested information on whether sexual coercion had
been experienced. The questionnaire concluded by assessing
whether the participant was living in fear of the persons
responsible for the DV, and if previous attempts to address
the problem had been made.
The study instrument described has been used success-
fully in previous studies of DV prevalence in our unit.8
The study received ethics approval from the National
Research Ethics Service (NRES) for Yorkshire and the
Humber—Sheffield and from the local research ethics
committee.
The anonymised data were entered into an EXCEL spread-
sheet and SPSS 19.0 was used for the analysis (IBM,
Chicago, IL, USA). The descriptive statistics were calculated
using percentages. A series of statistical tests were con-
ducted to analyse the data. To explore significant associa-
tions with the control variables (age, number of children,
etc.), a one-factor analysis of variance (ANOVA) was
conducted; to observe the relationship between DV during
ª 2014 Royal College of Obstetricians and Gynaecologists
Prevalence of domestic violence in ANC and TOP clinics
pregnancy and the rest of the variables (nominal),
nonparametric correlation tests were used. Percentages were
calculated from the total number of questionnaires;
however, small numbers of women did not answer each
question.
Results
In total, 507 women agreed to participate in the study. Of
these, 233 were recruited in ANC and 274 were recruited
from the TOP clinic. In total, 219/233 (94%) of the ANC
participants completed part or all of the form. Fourteen
other questionnaires were also found in the collection box
with no data recorded. The results are therefore based on
the 219 respondents. The entire population of the 274
women recruited in the TOP clinic either completed the
questionnaire forms in full or in part. Among the TOP
clinic participants, 5.8% were victims of physical abuse in
the current relationship, whereas 0.9% reported physical
abuse in the ANC population, regardless of pregnancy sta-
tus. The corresponding rates of physical abuse in pregnancy
were 4.7 and 0.9%, respectively. Women in the TOP group
also suffered a higher rate of emotional abuse than those
in the ANC population (9.9 versus 1.8%, respectively;
Table 1).
The survey showed that 93.4% of women in the TOP
study population were classed as white British, which is
similar to the prevalence in the ANC study population, in
which 92.2% were classed as white British. This is broadly
reflective of the ethnic demographics of the background
population.14 Most of the women (95%) had three children
or less, and 36% had no children at the time that the sur-
vey was conducted. Women recruited from the ANC popu-
lation were more likely to be married or in a relationship
compared with women from the TOP population
(Table 1). In women requesting TOP, 85/274 (31%) had
undergone a previous TOP. Of these women, 25% (21/85)
of them had had more than one repeat termination; how-
ever, only 7% (6/85) of these women admitted to experi-
encing DV in the current pregnancy or relationship. A
higher proportion of the total TOP population described
their relationship as being unsatisfactory or unstable than
the total ANC population [20/274 (7.3%) versus 5/219
(2.3%)]. Women requesting a TOP were less likely to have
a degree in comparison with the ANC population, where
22% of those had obtained a degree, although the women
requesting a TOP were also significantly younger, with a
mean age of 24.4 years, than those in ANC who had a
mean age of 28.8 years.
In the TOP group five women who suffered DV had
been forced to engage in sexual activity, and the main per-
petrators were either a boyfriend or an ex-boyfriend. Less
likely perpetrators included ex-husbands, as reported by
629
 Wokoma et al.

Table 1. Characteristics of women attending the antenatal clinic Table 2. Reasons for requesting a termination of pregnancy in 274
(n = 219) and those requesting a termination of pregnancy women
(n = 274)
Money worries 111 21%
ANC n (%) TOP n (%) P Contraception failure 108 20.5%
May affect education/career 77 14.6%
Marital status Family complete 71 13.4%
Single 54 (24.7) 163 (59.5) P < 0.0001 Not in a relationship/unmarried 61 11.5%
Married/cohabiting 154 (70.3) 79 (28.8) Unstable relationship 37 7%
Divorced/separated 9 (4.1) 24 (8.8) Do not think partner is suitable father 17 3%
Ethnicity Never wanted children 16 3%
White 202 (92.2) 256 (93.4) P < 0.201 Unsatisfactory relationship 11 2%
Black 2 (0.9) 4 (1.5) Violent relationship 10 2%
Asian 3 (1.4) 6 (2.2) Other 8 1.5%
Mixed 8 (3.7) 8 (2.9)
Women were allowed to give more than one reason; therefore, 527
Education
reasons were recorded, and 16 women did not give a reason.
GCSE 77 (35.2) 125 (45.6) P < 0.0001
A level 31 (14.2) 45 (16.4)
Degree 49 (22.4) 30 (10.9)
Other higher education 45 (20.5) 34 (12.4) In the ANC population, the women who disclosed DV
In a relationship had been abused by a boyfriend, ex-boyfriend, or ex-
Yes 195 (89.0) 181 (66.1) P < 0.0001 husband. The different types of physical abuse experienced
No 21 (9.6) 92 (33.6) involved slaps, pushing, punches, kicks, with bruises and
Feelings about relationship
cuts, being beaten up, severe bruising, and burns. There
Happy 178 (81.3) 131 (70.4) P < 0.0001
Satisfactory 13 (5.9) 31 (16.7)
was no sexual violence perpetrated in this group. Two
Unsatisfactory 3 (1.4) 9 (4.8) women who disclosed DV were afraid of a partner or
Unstable 2 (0.9) 11 (5.9) someone else. When asked if help had been sought, these
Emotional abuse women either declined to answer the question or stated
Yes 4 (1.8) 27 (9.9) P < 0.0001 that they had not sought help.
No 198 (90.4) 224 (81.8) The most common reasons that women gave for request-
Physical abuse
ing a TOP were financial worries and failure of contracep-
Yes 2 (0.9) 16 (5.8) P < 0.05
No 199 (90.9) 227 (82.8)
tives (Table 2). Only 2% (10/274) of the women recorded
Physical abuse in pregnancy DV as one of the reasons for seeking a TOP.
Yes 2 (0.9) 13 (4.7) P < 0.033
No 204 (93.2) 240 (87.6)
Discussion
Percentages refer to the whole cohort; however, small numbers of
women did not answer each question, and some women answered
Main findings
secondary questions inappropriately. All statistical analysis were Our study found a six times higher rate of DV in the TOP
performed using chi-square tests. population compared with the ANC population. Women
in this study who were requesting a TOP were more likely
to be younger, in unstable relationships, and less likely to
one study respondent. Most participants who admitted to have higher education than the women attending ANC.
DV were also forthright in identifying the perpetrator, with There was little ethnic variation between the two groups,
only one participant declining to respond. Most of the although the included numbers were small. This study
women had spoken to someone else about the problem, agrees with other studies where emotional abuse was found
but this person was most likely to be a friend rather than to be more prevalent than physical abuse.7,15 Domestic vio-
their general practitioner (GP) or other authority figure. lence was not the main reason given for requesting a TOP.
Two women had been physically hurt on four occasions, Financial constraints and contraceptive failure were cited as
and one woman said she had been hurt on more than ten the main reasons women requested a TOP.
occasions. In the TOP group, the majority of the women
who had been physically abused had been slapped or Strengths and limitations
pushed, punched, kicked, beaten up, or had severe bruising We believe that this is the first comparative study of DV in
and burns. Four women admitted to fear of a partner, or two cohorts of pregnant women that gives direct evidence of
any of the listed categories of people (husband, ex- the higher prevalence of DV in women requesting a TOP.
husband, boyfriend, ex-boyfriend, mother, father). The study was conducted in a National Health Service (NHS)

630 ª 2014 Royal College of Obstetricians and Gynaecologists


hospital. The NHS model is an all-inclusive model of health
care, and this would make the results transferable to the
general UK population. A limitation of the study was the
difficulty in separating women from their partner, or other
accompanying person, particularly in ANC, to be able to offer
them the questionnaire in private. This may have underesti-
mated the prevalence of DV. In addition, questionnaires were
handed out by healthcare professionals in the clinics, and
although the study did not investigate the attitude of health-
care professionals to DV screening specifically, we found that
some staff members appeared more willing to recruit partici-
pants to the study and to give out questionnaires than others.
We believe that the bias introduced as a result of this process
is minimal, as staff allocation to the clinics is arbitrary.
Interpretation
The results of this study confirm findings from previous
studies.8,15 It highlights concern pertaining to the TOP
population, where there is a higher incidence of DV than
in the general population. A US study confirmed that
women requesting TOP experienced an above-average inci-
dence of DV.16 Women who have experienced DV are con-
sistently found to have poor sexual and reproductive health
when compared with non-abused women.17 In our study,
we found financial constraints were the most common rea-
son for requesting a TOP. Many poor women requesting a
TOP have had many disruptive events in their lives, such
as unemployment issues and housing instability, leading to
the decision to terminate their pregnancies. A study by
Jones et al.18 showed that women were more likely to be
victims of DV emanating from disruptive conditions.18
The prevalence of DV in this study (0.9 and 5.8% for
physical abuse, and 1.8 and 9.9% for emotional abuse, in
ANC and TOP clinics, respectively) was less than in previ-
ous studies conducted in the same area that found 17% of
women reported DV8; however, this study requested infor-
mation on the current relationship and current pregnancy
only, and not over a broader lifetime perspective.
Previous studies have found that psychological abuse was
more prevalent, especially during pregnancy.19,20 We also
found emotional abuse was more prevalent than physical
abuse. Many abused women define the psychological effects
of DV as having a more profound effect on their lives, even
with life-threatening or disabling physical violence.21 A
pregnant woman’s mental, emotional, and physical health
bears a direct correlation with the presence of DV,6 and in
some cases is directly linked with postnatal depression.22
This effect of DV on a woman’s mental status has implica-
tions for women requesting a TOP, especially those with
mental health problems, where there is an increased risk of
adverse psychological sequelae.23
There was little ethnic variation between the two groups,
in agreement with the British Crime Survey (2004) that
ª 2014 Royal College of Obstetricians and Gynaecologists
Prevalence of domestic violence in ANC and TOP clinics
showed little variation in the experience of interpersonal
violence by ethnicity.24 We observed a reluctance of some
healthcare professionals in our unit in screening for DV.
Some studies show that healthcare professionals did not
agree to women being screened in a healthcare setting,25
and there is a gap in the evidence base for screening for
DV.26 Barriers to screening by healthcare professionals
included lack of training or experience of screening, fear of
offending or endangering patients, lack of effective inter-
ventions, patients not disclosing or not complying with
screening, and limited time.25
A limitation highlighted in our study was that it was
sometimes difficult to see women alone in order to recruit
them to the study or screen for DV. Men have for a long
time been encouraged to participate in health interventions
for their partners, and their attendance is now culturally
acceptable in most developed countries, especially during
antenatal visits. However, failure in being able to separate a
woman from the accompanying person at a clinic visit may
be a pointer to a coercive relationship. Reproductive con-
trol is known to be a factor in abusive relationships, where
the intimate partners exhibit controlling behavior and
determine the use or non-use of contraceptives, and invari-
ably the outcome of the pregnancy.17
It is well known that women may sometimes withhold
information for fear of the consequences. A study of men-
tal health services in London enumerated the barriers that
service users faced in the disclosure of DV to professionals.
This included fear of the consequences (including fear of
Social Services involvement and consequent child protec-
tion proceedings, fear that disclosure would not be
believed, and fear that disclosure would lead to further vio-
lence), the hidden nature of the violence, actions of the
perpetrator, and feelings of shame.21
Domestic violence remains a complex public health issue
that may start or escalate with pregnancy and ultimately
lead to the loss of fetal or maternal life. The tragic impact
of DV in maternity is well documented in the confidential
enquiries report ‘Saving Mothers’ Lives’.27 This is a small
fraction of the true scale of the problem, and health profes-
sionals looking after pregnant women during the antenatal
period or women requesting a TOP are well placed to help
and support women.
Conclusion
The newly revised Royal College of Obstetricians and
Gynaecologists guideline on women seeking induced abor-
tion has now included the recommendation that services
should identify the issues that make women particularly
vulnerable, for example DV, and refer them to appropriate
support services in a timely manner.23 This should be
implemented and robustly audited. For practitioners who
631
 Wokoma et al.
provide services, there should be training and support for
all relevant staff, standard definitions relating to DV service
provision allowing all agencies to work towards a common
purpose, good practice guidelines and standards, against
which services can be assessed and compared.28 Structured
pathways offer women the opportunity to disclose to health
professionals who sensitively and tactfully request the infor-
mation, and for those who accept help to be referred to
the appropriate services.
Our study has highlighted that the rate of DV was six
times higher in the TOP population than in the population
of women attending ANC. Even though DV was not given
as a frequent reason for requesting a TOP, the women in
the TOP population are at a higher risk of DV, and this
may be related to other life issues. We recommend more
research to determine effective and acceptable screening
methods and interventions to help women, particularly in
the TOP population. It is only when this has been com-
pleted that sufficient measures will be initiated to curb this
growing menace that poses a significant health risk.
Disclosure of interests
No competing interests to disclose.
Contribution to authorship
TTW was involved in the conception and planning of the
study, acquiring and analysing the data, and in drafting
and giving final approval of the article. MJ was significantly
involved in the acquisition of data, analysing data, and
drafting the article, and gave final approval for the article.
HB was involved in the conception and design of the
study, in the acquisition of data, and in drafting the article,
and gave final approval for the article. KG was involved in
the acquisition of data, in revising the article critically for
important intellectual content, and gave final approval for
the article. SL was involved in the conception and design
of the study, in the analysis and interpretation of the data,
and in drafting the article, and give final approval for the
article.
Details of ethics approval
The study received ethics approval from NRES Committee
Yorkshire and the Humber—Sheffield (ref. no. 10/H1308/
42; 12 August 2011). The sponsor was Hull and East York-
shire NHS Trust.
Funding
No funding was received for the study.
Acknowledgements
We thank Gill Barnett for assistance with inputing data
into the spreadsheet and Nkechi Emenike for editorial
assistance. &
632
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