How to Facilitate Disclosure of Violence while Delivering Perinatal Care: The Experience of Survivors and Healthcare Providers

Abstract

Gender-based Violence (GBV) during the perinatal period is a serious concern as it is associated with many adverse outcomes for both the mother and the baby. It is well known that violence is under-reported. Thus, official statistics (both police reports and survey data) underestimate the prevalence of violence in general and during the perinatal period specifically. In this study conducted in Canada, we sought to explore the barriers to and facilitators of women disclosing their experiences of GBV within healthcare services to safely facilitate more disclosure in the future and reduce the harms that arise from GBV. We used thematic analysis to analyze in-depth interviews with 16 healthcare providers (nurses, midwives and physicians) and 12 survivors of GBV. The data reflect three main themes: “raising awareness of gender-based violence”, “creating a shift in the healthcare system’s approach toward gender-based violence” and “providing support for survivors and care providers.” Our findings suggest that the healthcare system should increase its investments in raising awareness regarding GBV, training healthcare providers to respond appropriately, and building trust between survivors and healthcare providers. Healthcare providers need to be aware of their role and responsibility regarding identifying GBV as well as how to support survivors who talk about violence. Expanding a relationship-based approach in the care system and providing support for both survivors and health care providers would likely lead to more disclosures.

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https://doi.org/10.1007/s10896-022-00371-z
ORIGINAL ARTICLE
How toFacilitate Disclosure ofViolence whileDelivering Perinatal
Care: The Experience ofSurvivors andHealthcare Providers
AnnPederson1· JilaMirlashari2 · JanetLyons3· LoriA.Brotto2
Accepted: 1 February 2022
© Crown 2022
Abstract
Gender-based Violence (GBV) during the perinatal period is a serious concern as it is associated with many adverse out-
comes for both the mother and the baby. It is well known that violence is under-reported. Thus, official statistics (both police
reports and survey data) underestimate the prevalence of violence in general and during the perinatal period specifically. In
this study conducted in Canada, we sought to explore the barriers to and facilitators of women disclosing their experiences
of GBV within healthcare services to safely facilitate more disclosure in the future and reduce the harms that arise from
GBV. We used thematic analysis to analyze in-depth interviews with 16 healthcare providers (nurses, midwives and physi-
cians) and 12 survivors of GBV. The data reflect three main themes: “raising awareness of gender-based violence”, “creating
a shift in the healthcare system’s approach toward gender-based violence” and “providing support for survivors and care
providers.” Our findings suggest that the healthcare system should increase its investments in raising awareness regarding
GBV, training healthcare providers to respond appropriately, and building trust between survivors and healthcare providers.
Healthcare providers need to be aware of their role and responsibility regarding identifying GBV as well as how to support
survivors who talk about violence. Expanding a relationship-based approach in the care system and providing support for
both survivors and health care providers would likely lead to more disclosures.
Keywords Perinatal care· Gender-based Violence· Disclosure· Facilitators· Healthcare providers· Women
Introduction
Gender-based violence (GBV) is violence directed at an
individual based on their sex or gender identity. It encom-
passes a wide range of abuses such as sexual threats, rape,
exploitation, humiliation, assault, molestation, domestic vio-
lence, incest, torture and depriving women of their right to
enjoy their freedom and having control over their life (Blon-
deel etal., 2018; Sinko etal., 2021). GBV can also affect
members of the LBGTQ + population, men, and individuals
who identify as gender non-binary (Blondeel etal., 2018;
Graaff, 2021) In Canada, GBV disproportionately affects
women, girls, Indigenous women, women with disabilities,
and women living in rural or remote regions. Also, individu-
als of diverse gender identities and expression are at greatest
risk of violence (Chmielowska & Fuhr, 2017; Government
of Canada S. of W. C., n.d.; Nelson & Lund, 2017; Valen-
tine etal., 2019).
The detrimental effects of violence for mothers and their
developing fetuses during the perinatal period are more pro-
nounced than among survivors who experience violence out-
side the perinatal time (Taillieu etal., 2016). The perinatal
period in this study is defined as the pregnancy period up to
a year after giving birth (Garcia & Yim, 2017). In fact, vio-
lence during this time is a serious concern; it is associated
with adverse outcomes such as premature birth, miscarriage,
* Jila Mirlashari
jila.mirlashari@ubc.ca
Ann Pederson
apederson@cw.bc.ca
Janet Lyons
JLyons4@cw.bc.ca
Lori A. Brotto
lori.brotto@cw.bc.ca
1 Population Health School ofPopulation andPublic Health,
University ofBritish Columbia, Vancouver, Canada
2 Department ofObstetrics andGynecology, University
ofBritish Columbia, Vancouver, Canada
3 Division ofGeneral Gynecology & Obstetrics, University
ofBritish Columbia, BC Women’s Hospital, Provincial
Health Services Authority (PHSA), Vancouver, Canada
/ Published online: 22 March 2022
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1 3
low birth weight, admission to a neonatal intensive care unit,
sexually transmitted infections (Paterno & Draughon, 2016),
depression, substance use and financial difficulties (Taillieu
& Brownridge, 2010).
Unfortunately, GBV is under-reported; in 2014, fewer than
19% of those who had been abused by their partner reported
the incident to police. Consequently, most cases of abuse and
violence are not captured in official statistics (Family Vio-
lence in Canada: A Statistical Profile, 2014, 2014). A recent
report suggests that more than one-third of survivors wait for
more than two years before disclosing the abuse (Boethius &
Åkerström, 2020). The prevalence of violence during preg-
nancy in developing countries is estimated as 27.7% and in
developed countries as 13.3% (Stewart etal., 2017). Indeed,
the highest prevalence of violence is reported among women
of reproductive age, with the highest rates occurring among
individuals 18 to 34years old. Clearly, women in theirperi-
natal periodare not immune from GBV. Therefore paying
special attention to GBV within the reproductive health set-
ting is essential. (Bair-Merritt etal., 2014; Taillieu etal.,
2016) These data demonstrate the need to focus attention on
GBV during the perinatal period (Hahn etal., 2018).
To assess the effectiveness of screening for violence within
health care settings on identification, referral, and re-exposure of
violence and evaluation of women’s health outcomes, Doherty
etal. did a review. They included 13 trials that recruited 14,959
women from diverse healthcare settings. The settings were pre-
dominantly located in high-income countries and urban areas.
They explained that women during their perinatal care might be
more likely to disclose GBV when screened for experiences of
violence. However, there is no evidence showing that screening
by itself impacts other outcomes such as referral, re-exposure to
violence and health measures when not accompanied by inter-
ventions that can support the victim. Thus, while identification
of GBV increases by screening, there is insufficient evidence to
justify screening in healthcare settings (O’Doherty etal., 2015).
Although most studies emphasize the importance of disclosure,
there is still no consensus among all diverse schools of thought
regarding screening. British Columbia (BC) Women’s Hospital
& Health Centre does not currently conduct screening for vio-
lence because staff and leaders lack training. Also, they believe
in BC, there is limited infrastructure for GBV services. At pre-
sent, the hospital’s policy is to inquire regarding violence when
there are signs that it may be present rather than to offer universal
screening. This case-finding approach is supported by trauma- or
violence-informed approaches to perinatal care (Rossiter, 2011).
In agreement with this approach, WHO mentioned that there is
insufficient evidence supporting the idea that screening reduces
GBV or improves the quality of life or health outcomes (Mac-
Millan etal., 2009).WHO also stipulates the necessity of certain
conditions before application of GBV screening, such as access to
trained health care providers who can speak to women privately
and are able to provide post-screening interventions. Therefore,
screening application is difficult in some clinical settings with
low resources and lack of training (Bacchus etal., 2010; MacMil-
lan etal., 2009; O’Reilly & Peters, 2018).
Although the health sector is one of the primary resources
for women who have survived abuse, the perinatal care
providers’ role in GBV intervention programs is currently
limited (Purwaningtyas etal., 2019). While care providers
agree that violence against women is a healthcare issue, it is
nevertheless often overlooked in clinical settings (Ramsay
etal., 2012; Usta & Taleb, 2014).
The literature suggests several factors contribute to healthcare
providers’ limited assessment of GBV in their practice, includ-
ing providers’ personal discomfort with the topic; perceived inad-
equate resources to address GBV; lack of time; and lack of training
(Hegarty etal., 2020). Many clinicians feel poorly prepared to ask
relevant and sensitive questions about GBV; many reports not hav-
ing access to a private place to raise the topic (Paterno & Draug-
hon, 2016). Other documented barriers include the perception
that assessing violence is not the clinician’s role; fear of offending
women; and uncertainty regarding how to respond to a disclosure
of violence (Paterno & Draughon, 2016; Portnoy etal., 2020).
Women themselves have identified various reasons for
not disclosing experiences of violence during the perina-
tal period, including self-blame; shame; fear of the con-
sequences; lack of knowledge of services (Shaheen etal.,
2020); concerns that child protection officials will become
involved; fear of not being believed; and fear that disclo-
sure might escalate or exacerbate the violence (Curry etal.,
2011). There is some literature on the effective facilitators
of GBV disclosure. For example, many of the barriers can
be addressed through proper training and the development of
a systematic inquiry protocol (Paterno & Draughon, 2016).
A qualitative study was conducted in UK in London’s men-
tal health centers to explore the facilitators and barriers to
domestic violence disclosure from a service user and profes-
sional perspective. Both healthcare providers and survivors
reported that supportive and trusting relationships between
clients and care professionals would facilitate disclosure
(Rose etal., 2011). The extent to which survivors perceived
they would be deemed credible and would receive tangible
emotional support from care providers have also been identi-
fied as facilitators of disclosure (Curry etal., 2011). There-
fore, communicating with compassion, providing informa-
tion and asking questions in a private, safe and supportive
atmosphere, and explaining why questions have been asked
are reported to help women feel more comfortable disclosing
(Chang etal., 2005). In these supportive circumstances, sur-
vivors might report experiencing less stigma when sharing
their stories with healthcare providers (Chang etal., 2005;
Murray etal., 2016).
Previous research on GBV and healthcare has not typi-
cally focused on the perinatal period. Receiving first-hand
information from survivors and care providers regarding
572 Journal of Family Violence (2023) 38:571–583
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1 3
facilitators of the disclosure may help decision-makers
design interventions and programs that are more compat-
ible with the existing context. This study aimed to learn
from survivors’ and healthcare providers’ experiences about
facilitators of disclosure during perinatal healthcare in BC.
Methods
Participants In qualitative research, data saturation will
determine the number of interviews. In this study, we inter-
viewed 28 participants, 16 healthcare providers (nurses,
midwives and physicians) and 12 survivors.
Setting Healthcare providers were recruited from maternity
services and NICUs in different parts of British Columbia.
The survivors were from several various metropolitan cent-
ers in British Columbia.
Inclusion and Exclusion Criteria for the Survivors being
between the ages of 18–49, having been pregnant during the
last five years, having a self-reported history of GBV in the
perinatal phase, and communicating and speaking conver-
sational English. In a short pre-interview session, survivors
were asked about the experience of current drug dependency
and severe mental health problems. Since the experience of
current drug dependency and major mental health problems
could influence the experience of GBV, self-reports of cur-
rent alcohol or drug dependency and major mental health
problems (such as major depression and severe bipolar dis-
order) have been considered as exclusion criteria.
However, women who had an experience of drug depend-
ency in the past and those who were involved in the rec-
reational use of drugs were not excluded. In order to con-
sider maximum variation, survivors with diverse identities
(including those identifying as Indigenous and immigrants)
were recruited.
Inclusion Criterion for the Healthcare Providers Having the
experience of providing perinatal healthcare to women with
a history of GBV. Healthcare providers were recruited from
different parts of British Columbia.
Procedures For participant recruitment, flyers and adver-
tisements in settings such as hospitals and public places like
community centers, shelters, shopping malls, gyms, family
services, and courts were distributed. Social media adver-
tisements (i.e., Instagram and Facebook) and snowball sam-
pling were used to recruit additional participants. An office
telephone number and email were provided in the advertise-
ment for potential participants to contact the researcher.
Before the interviews, demographic characteristics, inclu-
sion and exclusion criteria were assessed by a short tele-
phone conversation, and comprehensive information about
the study was provided. Participation in the study was vol-
untary, and the same recruitment method was used for both
groups. Before the interview, consent was received from the
participants, and they were assured that their personal infor-
mation, transcripts, and recorded files would be anonymized.
Interview questions were designed by one of the research-
ers (JM) and finalized after discussion and exchange with the
team members. Semi-structured interviews were conducted
by JM, who has extended experience in qualitative research
and interviewing. Out of 28 interviews, ten were carried
out in person (in a cafeteria or healthcare facility), and
after COVID -19 pandemic, interviews were conducted via
phone. Women were asked about their experiences regard-
ing violence and the responses they received from the health
care system. Both groups were asked about underlying rea-
sons that made some of the survivors break the silence and
talk about their experience of violence with health care
providers. We asked about their suggestions for improving
the existing context of identifying GBV within the health
care system. Furthermore, care providers talked about their
approach toward the assessment of GBV. (Tables1 and
2show examples of semi-structured questions in interviews
with care providers and survivors).
Ethical Consideration The UBC C&W Research Ethics
Board approved this study (Approval number: H19-02,409).
The researchers ensured that the appropriate procedures
were followed regarding informed consent, anonymity,
autonomy, and maintaining confidentiality.
Data Analysis A qualitative approach was used to explore
participants’ thoughts, experiences, and recommendations
Table 1 Examples of semi-structured questions in interviews with survivors
1. How do you define GBV?
2. Who was the first person that you decided to talk about the experience of GBV with?
3. Have you ever had the experience of asking for help from a health care provider? If yes, please explain what made you disclose it to a health-
care provider?
4. Over the course of pregnancy and after that, did anyone in the health care system ask you about your history of abuse or violence?
5. What are the facilitators to disclosing violence based on your experience?
573Journal of Family Violence (2023) 38:571–583
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1 3
regarding facilitators of disclosure. Twenty-eight interviews
were conducted. Interviews lasted between 30–60min. Data
collection and analysis occurred simultaneously; each inter-
view audio file was transcribed verbatim and analyzed, and
then the next interview was conducted. After each interview,
the researcher wrote reflective notes and memos. This iterative
approach is recommended to enhance the value and quality of
the findings as subsequent interviews are informed by previ-
ously collected data (Suter, 2012). Simultaneous analysis helps
the researcher to be more confident about obtaining rich, deep
and related data so that the researcher learns from each inter-
view and its analysis to have a better interview with the next
participant and would be able to cover the gaps (Suter, 2012).
A thematic, inductive approach was used to analyze the
data (Nowell etal., 2017) using NVIVO. All interviews were
conducted by one of the team members. Two of the research-
ers who were expert qualitative researchers did the analysis
separately and then discussed their themes with the rest of the
research team. The entire text was read several times to iden-
tify meanings or possible patterns. We conducted line-by-line
coding to stay close to the data and preserve the action and
language represented in the text. After that, initial codes were
identified, and the data wereorganized into meaningful groups
and sorted into potential themes and subthemes. Moreover,
themes and subthemes were reviewed in terms of internal and
external consistency. Based on the suggestions of other team
members, some themes were modified, and a short and concise
name was chosen so that the readers would understand each
theme. The analysis suggested that both survivors and health-
care providers shared a number of similar perspectives, and
we, therefore, present the findings from both groups together.
To support the trustworthiness of the findings, Lincoln
and Guba’s proposed criteria, including credibility, confirm-
ability, dependability, and transformability, were considered
(Nowell etal., 2017). Strategies used to support trustwor-
thiness included repeated readings of the transcripts and
prolonged engagement with the data. Moreover, emerged
themes and subthemes were reviewed with team members.
To prevent insider bias, the researcher practiced reflexiv-
ity and documented personal reflections in a project diary.
Also, transferability increased by a complete description of
participants and process. In our report, we followed the Con-
solidated Criteria for Reporting Qualitative Health Research
(COREQ) so that readers can assess the credibility, depend-
ability, transferability, and confirmability of the study find-
ings (Tong etal., 2014).
Results
Participant Characteristics Twelve interviews were con-
ducted with survivors who had experienced pregnancy
within the last five years; the mean age of these women
was 35years old. In order to consider maximum variety, we
interviewed survivors with different backgrounds, ethnicity
and sociodemographic status. Sixteen interviews were also
conducted with healthcare professionals who had provided
care for women with a history of GBV (five nurses, five
midwives, and six physicians including family physician,
OBGYN and a neonatologist). The mean age of care pro-
viders was 40years old. Demographic characteristics of the
participants are presented in Tables3 and4.
Table 2 Examples of semi-structured questions in interviews with healthcare providers
1. How do you define GBV?
2. Have you ever come in contact with cases of GBV among your clients? Please explain how did you notice that and what was your response?
3. Over the course of pregnancy and after that, do you usually assess your clients for a history of violence/abuse?
4. What is the role of healthcare providers regarding GBV?
5. Based on your experience, how is it possible to increase the care provider’s level of involvement in the identification of GBV?
6.How can healthcare providers encourage disclosure?
Table 3 Demographic characteristics of health care providers
Profession Age range Years of experience as
a HCP
Physicians 35–54 8–28
Nurses 29–50 8–20
Midwives 34–59 2–20
Table 4 Demographic characteristics of survivors
Age Ethnicity Education Level
1 21 Latina Undergraduate student
2 35 European Master’s degree
3 41 Indigenous Elementary
4 40 Indigenous High school
5 27 South Asian Undergraduate student
6 38 Euro-Canadian Master’s degree
7 37 Latina Bachelor degree
8 39 Euro-Canadian College
9 40 Euro- Canadian College
10 35 East Asian Bachelor degree
11 27 Euro- Canadian Diploma
12 42 Euro- Canadian University (not finished)
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1 3
Thematic Findings The data can be clustered into three main
themes and 13 subthemes that all refer to how to improve
the response and system. (Table5 shows the main themes
and subthemes) (Fig.1 - the diagram of the main findings).
Main Theme #1: Raising Awareness ofGender‑Based
Violence
The need to raise awareness in the community was one of the
common topics mentioned by both groups of participants.
Study participants suggested that greater awareness of GBV
could change both individual survivors’ as well as broader
societal views toward disclosure, thereby encouraging sur-
vivors to seek help and support.
“I think what would play a big role is more aware-
ness, like people talking more about it, like how we
see ads in the film, in the movies or like when you are
watching TV in the evening. I think just having a small
one-minute ad, what GBV is? Have you ever suffered,
you know, violence or just the community needs to
get more awareness? I think that is, you know, media,
newspaper, Internet.” (35yr old Physician).
“I think certainly education is important. We can
inform them and tell them these are examples of vio-
lence, and this is what it sometimes can look like, or
these things could happen to you and are you interested
in getting more resources or learning more about this?
And there are some places you can go to learn more
about this.” (48yr old Physician)
“I talked about it with everybody with friends and
neighbours and family, and nobody identified it as
abuse. Everybody just said, oh, well, he is an idiot,
or oh, he was a jerk, or it probably was your fault. I
would have been out of the relationship for a while
that I found resources online. Actually, that made me
realize that this is abuse. And then I got a counsellor
to help me with it. I did not know until way after it
happened; I did not even recognize it as abuse.” (41yr
old Survivor).
Reducing the Stigma of GBV Disclosure Participants noted
that the stigma of disclosure makes women stay silent. They
mentioned that there should be more effort to de-stigmatize
GBV disclosure in society
“We need to talk about it. I guess in our society it is
easier to talk about suicide and depression than GBV.”
(34yr old Midwife).
“So I would definitely say society does not want to
hear about it just like most things with the status quo.
And there are fewer people in the middle of being open
to it.” (36yr old Midwife)
Validate Survivors’ Experiences Participants were concerned
about not being believed, and health care providers confirmed
Table 5 Overview of 3 major themes and 13 sub-themes
Raising awareness of gender-based violence -De-stigmatization of GBV disclosure in the society
- Validate survivors’ experience
-Reform gender inequality in society
- Create a positive attitude towards the supportive role of the healthcare
system by raising awareness
Creating a Shift in the healthcare system’s approach towards GBV -Adopt a relationship-based approach to healthcare
-Ensure continuity of care during perinatal period
-Establish a safe and secure atmosphere for disclosure
- Establish a multicultural approach
- Eliminating time constraints and work overload in the healthcare
system
-Clarify the role of healthcare providers with regard to GBV
Provide support for survivors and care providers -Health care providers training
- Support healthcare providers by paying the fee for the service
- Providing insurance coverage for the counselling services
Fig. 1 The diagram of facilitators of disclosure
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1 3
this concern. Perhaps a lack of awareness about GBV in the
community and the healthcare system contributes to doubt
toward survivors. Participants spoke about the importance of
empathy and receiving respectful, non-judgmental responses
from health care providers and society.
“Being believed is another issue, the fear that someone
will not believe you. That is really all I can think of, in
my particular case.”(42yr old Survivor)
“When she went into labour, it was a really hard situ-
ation. She always was screaming a lot every time any-
body tried to touch her. The hardest thing was that
while this was happening, the other health care provid-
ers were not very supportive. They did not understand
what was going on, and they were making fun of her.
Essentially. The anesthesiologist said, ‘well, you just
need to let us know how dilated you are to get the epi-
dural.’ Right? So withholding care from her.” (36yr
old Midwife)
Reform Gender Inequality in Society Referring to a soci-
ety in which men still have the upper hand, participants
explained that, in their experience, this fact could be a bar-
rier to disclosure. They believed that gender inequality in
society needed to be reformed.
“Traditionally, it is predominantly a male-influenced soci-
ety and women are often silenced over hundreds and hun-
dreds of years. There is still some of that present in today
is society, just because that culture has been around for
so long. So, I think that we are more supportive than we
have been in the past, but we are still not fully viewed as
equally or want to be heard as equally.” (29yr old Nurse)
“They just did not recognize it as something seri-
ous. They just kind of thought, well, men behave like
men, you know. It is just this cultural and social thing
about ‘oh you’re probably going to be mistreated,
and he is not hitting you, so it is okay.” (41yr old
Survivor)
“I think it is a very male dominant society. Very, you
know, white-dominated. So I think it is more than just
gender. I think that there’s a lot of sort of domination
and inequality…but I think being a minority also, you
know, is kind of like a double hitter.” (36yr old Mid-
wife)
Create a Trusting Relationship Between Care Provider and
Survivor by Raising Awareness Based on the participants’
experiences, many survivors were unsure about receiving
support from the health care system because they thought
the healthcare system’s focus was on physical problems.
At the same time, they were concerned that the care pro-
viders would report the violence to the police. Fear of
losing their children and financial hurdles also prevented
survivors from disclosing the violence. Therefore, creat-
ing a positive dynamic and trusting relationship between
the health system and survivors through raising awareness
plays a crucial role in disclosure.
“They know that health care providers have the duty
to report, and it leads to very serious legal ramifica-
tions for their families. So they do not feel health care
providers as safe people who actually have any kind
of solutions for them. And so why would you report?”
(35yr old Midwife)
“I was scared like, “What if they call the ministry?
Yeah, that is probably the most common fear, fear of
losing children, or losing home, you know, losing the
partner.” (40yr old Survivor).
“I think women would talk about it if they feel safe
to do so. But I understand why a lot of them do not
feel safe to do so…you know, they can’t trust the care
provider to do anything with the information.” (27yr
old Survivor)
Main Theme #2: Creating aShift intheHealthcare
System’s Approach Towards GBV
Participants pointed to the need for fundamental cultural
changes in the health system’s approach to GBV. They talked
about systemic sexism and stressed that this change should
be done in multiple layers across the healthcare system.
“It’s a system model of care shift that has to happen
as well. It is also about larger education about sexism.
Like all the ‘isms’ that kind of allow for GBV to hap-
pen within healthcare provider curriculum.” (35yr old
Midwife).
“I think everyone focuses on the medical piece of it,
but I think the social support piece and those aspects I
think they still do not pay enough attention to, so yeah,
I do not think we do a good job to still recognize the
importance of it. It’s still under-recognized. I think it
speaks to a systemic and cultural sort of shift of us
shifting from fixing things to learning about people’s
values and their life and what’s going on for them and
building relationships, so I think it’s a shift between
medicalizing everything to being preventative and
focusing on other things”. (45yr old Physician).
Adopt a Relationship‑Based Approach in Healthcare Sys‑
tem Some participants criticized the quality of commu-
nication between healthcare workers and survivors. They
argued that healthcare providers are very task-oriented.
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1 3
Some suggested that efforts are needed to establish a more
relationship-based approach to support women being will-
ing to disclose.
“I think the second thing is that the system is not set
up for kind of open and kind of relationship building
and open based questions. It is set up for task-based
oriented things in the fee for services system, so I
think we are kind of, it makes it hard to do this type of
work”. (37yr old Physician).
“Of course, the care provider should ask about the his-
tory of violence and talk about it with their clients.
But it has to be done in a way that is non-judgmental,
non-punitive and non-shaming. Without that in place,
it is going to do more harm than good. You are gonna
completely lose the trust of your clients.” (42yr old
Survivor 12).
Ensure Continuity of Care During the Perinatal Period Some
survivors mentioned that visiting different healthcare pro-
viders can disrupt the care relationship and trust-building
between women and their care providers during perinatal
care. The possibility of meeting one specific care provider
during the perinatal period can be instrumental in disclosure.
“So we feel a woman is meeting a new nurse every day
or a new doctor every day. It’s really hard to build that
trust and talk about these issues.” (42yr old Physician).
“It is really a sort of a collection of different doctors
and midwives that work together. I just went to the
Midwife, and often a client like myself would just see
a few different midwives during the course of their
prenatal support.”(38yr old Survivor).
“I guess another one of my problems is my family
doctor is floating all the time. I had one woman, and
then she left on mat-leave. Now I see some floater
doctors; I just have a rotating group of women doc-
tors, so I do not think many of them are reading back
into my charts or anything or trying to put it together;
they were just dealing with the appointments as they
came. You are only allowed to talk about two things
at a time. And they kind of, it feels like they are kind
of pushing you out.”(39yr old Survivor)
Establish a Safe and Secure Atmosphere for Disclosure The
participants believed care providers should ask questions
related to safety and GBV. However, they stressed that these
questions should be asked in a private and safe environment.
They also spoke about confidentiality and the quality of the
conversation between care providers and survivors. It seems
that the healthcare system should take action in creating an
atmosphere in which women feel comfortable enough to talk
about sensitive topics like GBV.
“The person who is having to disclose their own expe-
rience should be disclosing it in a safe environment.
So, if I ask someone directly with a cold question, it is
unfair to expect them to answer.”(59yr old Midwife).
“I would never have admitted anything while he was
there. I’m still afraid, even calling or sending emails
or anything. I feel like he is watching me. I still take
precautions.”(37yr old Survivor).
Establish a Multicultural Approach The participants suggested
that health care providers should pay more attention to cultural
differences whendesigning programs for supporting survivors.
They discussed the idea that there are different definitions of
GBV in different cultures and suggested that care providers
need to be more aware of these differences. Having a single
approach toward GBV while ignoring the impact of multicul-
turalism on experiences may limit the disclosure.
“I think every year, doctors, psychologists, anes-
thesiologist, midwives, anybody that is going to be
providing care to women and trans peoples, should
be doing some kind of training, and then also we
want to discuss how that affects across race and you
know, with cultural safety training led by the people
from that community. So if it is Indigenous cultural
safety, having it be led by an Indigenous person, if it
is Black women, Trans women, having their experi-
ence be a part of the training, like the voice for doing
the training if that makes sense.”(36yr old Midwife)
“There needs to be more education on culture and
cultural practices. Within cultures, there are tons of
different practices and mannerisms and traditions.
So, in westernized, like Canadian culture, something
that we see or hear in a different culture might come
across as something of a red flag, but it is completely
normal for them. Every culture is different. So we
have to still provide culturally sensitive care”. (29yr
old Nurse)
Clarify the Role of Healthcare Providers with Regard to
GBV Some healthcare providers mentioned that dealing with
GBV was not their responsibility, and they used to assume
that this was not in their scope of practice. Some survivors
also mentioned that addressing GBV is not among the duties
of healthcare providers and that they did not know that they
could receive support from healthcare providers. Accord-
ingly, healthcare providers’ roles and responsibilities regard-
ing GBV should be discussed during clinical training and
continuing education. Clarifying healthcare providers’ roles
and responsibilities regarding GBV will clear up ambigui-
ties, makingthe health care providers and the survivors more
aware of the health professionals’ positions, and providing
them with an opportunity for identification and disclosure.
577Journal of Family Violence (2023) 38:571–583
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1 3
“They do not see it as their job. They see their inter-
action with their patient is to provide a certain service,
and we do not see the extent to which GBV impacts. Some
people do not take responsibility that it’s in their realm.
So they think, oh, someone else will document that. That’s
a social issue when really it is the responsibility of every
care provider.” (48yr old Physician).
“I think that is not their job, they are midwives and fam-
ily doctors, and they just help the baby like delivering the
baby.” (35yr old Survivor).
“And, again, I think it is because it has been outside in
the traditional realm of health care providers skills and
knowledge base I think it is thought of more of like social
work.” (35yr old Midwife).
Eliminate Time Constraints and Work Overload in the Health‑
care System From the participants’ point of view, violence
and disclosure are very sensitive topics that require time
and trust between the care provider and the survivor. They
pointed out that care providers’ time constraints and work-
loads made women feel that the health care system was not
ready to address GBV.
“…when you feel devalued then if you were talking with
medical professionals and they are overloaded you were
not going to stand there that way.” (35yr old Survivor).
“I think it is time restriction and exhaustion, burnout, and
just feeling too overextended. Physicians, for example, do not
spend as much time with clients as midwives do. So I imagine if
you have a 10-min appointment, you’re not going to be solving
all of these problems”. (36yr old Midwife).
Main Theme #3: Providing Support forSurvivors
andCare Providers
Both care providers and survivors explained that they needed
more support. Health care providers insisted on the impor-
tance of training, reducing their workload, and receiving
compensation for service. Survivors also said that they
needed more information. They mentioned that they could
not afford to pay the fees for counselling and that this was
one of the barriers to disclosure. Health care providers con-
firmed that the counselling fee prevented some survivors
from seeking help.
Healthcare Provider Training Most participants observed
that healthcare providers were not sufficiently prepared to
identify GBV and did not know the best supportive approach
after disclosure. They believed that universities and health
settings should make more effort to train care providers and
provide them with instructions on dealing with GBV.
“My suggestion for the healthcare system is, keep
learning, keep talking, and keep listening.
Treat the mental health of female patients as a priority,
not as a hindrance or an afterthought.
So, I believe that would be the only solution I can see
at this point.” (42yr old Survivor).
“I have not had any formal training in addressing gen-
der violence or partner violence. I have never been
given any strategies of how to approach that conver-
sation with women or men, or whatever their gender
might be.” (29yr old Nurse).
“I do not know how to start the conversation. How do
I make them talk and explore their situation? I actually
have been here for 20years, and I have not formally
attended one workshop that really shows me how to be
prepared for it.”(47yr old Nurse).
Support Healthcare Providers by Paying the Fee for the
Service In this study, physicians mentioned that perform-
ing assessment and providing support for survivors is time-
consuming, and they should receive appropriate payment
for this service. It was interesting that survivors were aware
of this issue, and from their perspective, one of the reasons
that physicians could not address GBV was not receiving
adequate money for this service.
“The system needs to change its structure, we are going
to create time within our system, and we are going to
pay people to spend time talking to women about this
issue. If you cannot pay your overhead cause you have
to see a certain number of patients. You know. You are
responsible for this” (48yr old Physician).
“I think the biggest distance gap is how physicians
are remunerated. Uh, the fee-for-service model does
not facilitate people taking time to ask these questions
or respond if the questions are positive”. (37yr old
Physician).
“So if my doctor takes more than 15min to talk to
me, he cannot bill for this extra time, which is why
the clinics race through the people so fast. (41yr old
Survivor).
Providing Insurance Coverage for the Counselling Ser‑
vices Providing support and counselling systems covered by
insurance can encourage women to disclose their experience
of violence. They need to be assured that disclosure would
lead them to free support services. According to the inter-
views, the high cost of counselling and the lack of adequate
insurance coverage led some women to refuse to disclose
violence because they could not afford counselling fees.
“I have done a little bit of counselling, so I have talked
to counsellors a little bit because counsellors are really
578 Journal of Family Violence (2023) 38:571–583
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1 3
expensive, and insurance does not cover counselling.”
(41yr old Survivor).
“The doctor did recommend some therapists to me, but
I could not afford them.” (42yr old Survivor).
Discussion
The factors that may facilitate disclosure of GBV for preg-
nant and newly-parenting patients are complex and context-
based. In this study, three main themes were identified that
would each facilitate survivors of GBV in the perinatal
period to disclose their experience: (1) Raising awareness
about GBV; (2) creating shifts in the healthcare system’s
approach to GBV; and (3) providing support for survivors
and care providers.
“Raising Awareness”: For some of the survivors, these
interviews were the first time they had spoken about the vio-
lence since being silenced. Survivors were unable to speak
out about their experiences for many underlying reasons,
including lack of knowledge and awareness, fear of disclo-
sure and its consequences, not having access to resources
and support, not having trust inthe health care system, self-
blaming and adverse reactions of people in their community
and health care setting. Raising greater awareness of GBV
might create contexts that support disclosure, where sur-
vivors would feel more comfortable speaking about their
experiences.By raising awareness, the participants meant
raising awareness in society, among pregnant women, and
among perinatal healthcare providers. This finding is con-
sistent with previous research, which has documented that
raising awareness and fostering a better understanding of
the consequences of GBV during pregnancy and the peri-
natal period could lead to the design of strategies aimed at
preventing violence, increasing early detection, and more
timely interventions (Taillieu etal., 2016). A Canadian qual-
itative study involving focus groups with health profession-
als reported that the public’s inherent trust in the medical
profession facilitates care providers’ readiness to address
GBV (Sprague etal., 2013).
To facilitate identification and disclosure of violence,
the participants of their study suggested the need for rais-
ing awareness, possibly through posters in perinatal health-
care settings, increased education and training for perinatal
healthcare providers, and providing resources for survivors
(Sprague etal., 2013). In a study conducted in the UK, care
providers’ attitudes towards survivors of GBV were gener-
ally positive. However, UK health care providers reported
they only have a basic knowledge of GBV and that they
needed more comprehensive training on this subject. They
particularly mentioned that they need to have more informa-
tion about available local services that could support survi-
vors (Ramsay etal., 2012).
In addition to raising awareness, it is essential to pay atten-
tion to the underlying causes of GBV in society. The causes
of GBV may vary based on the context and culture of each
community. Therefore, designing programs and interventions
should be developed based on the context (Perrin etal., 2019).
Our study participants talked about care providers who believe
in survivor’s stories and mentioned the importance of this ten-
dency for disclosure. Validating women’s experiences, provid-
ing a safe atmosphere without judgment, and creating empa-
thy could lead to more patient disclosure of GBV (Hegarty
etal., 2020; Tarzia etal., 2020). There is growing evidence
that women are willing to discuss experiences of GBV with
healthcare providers (Tarzia etal., 2020; Usta etal., 2012).
Also, women during their perinatal care may be more likely to
disclose GBV, especially if the issue is raised by the care pro-
vider (O’Doherty etal., 2015). Therefore, healthcare providers
should be trained to effectively identify, assess, and respond to
GBV (Tarzia etal., 2020).
When our study participants were asked about under-
lying reasons for remaining silent and what would have
facilitated disclosure, they explained that they were unsure
about healthcare providers’ role regarding GBV. They were
concerned that they would not be believed and validated
by healthcare providers. In some situations, survivors who
spoke out about their assault experiences said that they
were ignored or devalued. These negative experiences seem
to silence survivors. Our findings are consistentwith the
results of a study conducted in Sweden in which partici-
pants reported being concerned about the reactions of fam-
ily, friends, and community to their disclosure and the effect
of disclosure on their social interactions. The survivors who
decided to speak up despite potentially negative outcomes
referred to their need for emotional and practical support
(Boethius & Åkerström, 2020). Perhaps when survivors are
informed of the support they will receive from the health-
care system, they might be more inclined to disclose. As
previously noted, the willingness of providers to hear about
disclosure could be advertised through posters in perinatal
health care settings, social media, and websites.
Study participants mentioned that Canadian/Western
society is still patriarchal; some suggested that disclosure
would become easier if men and women had equal rights
and power. They suggested that gender inequality is a fun-
damental cause of GBV, a perspective supported by data
that documents that gender inequalities increase the risk of
violence by men against women and inhibit the ability of
those affected to break the silence and seek help and protec-
tion (Health Promotion vs Health Protection, n.d.).
Creating a Shift in the Healthcare System’s Approach Towards
GBV Study participants argued that the healthcare system’s
policy towards GBV should be revised; they proposed that a
shift in the model of care to relational practice should replace
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1 3
the current task-oriented approach. Evidence from other stud-
ies similarly mentions that fostering empathy and a positive
relationship between survivor and healthcare providers would
facilitate disclosure (Rose etal., 2011). Study participants also
spoke about the importance of creating safety and confidential-
ity to support survivors to disclose experiences of abuse. Evi-
dence shows that shame, fear of judgment, not being believed,
and confidentiality concerns were among the main reasons
for nondisclosure among survivors. Therefore, building trust,
providing a safe atmosphere without judgment, and creating
empathy could lead to more disclosure (Ahrens, 2006).
Healthcare providers should show their willingness to
assist survivors safely while considering confidentially and
respecting a woman’s right to choose whether or not to dis-
close a history of violence (Registered Nurses’ Association
of Ontario, 2005).
Some of the participants from both groups in this study
were not sure that addressing GBV was within the scope
of medical practice. Evidence suggests that survivors and
care providers need to know that dealing with GBV is a
healthcare provider’s role (Usta etal., 2012). As noted, if l
healthcare providers do not identify GBV as falling within
their scope of practice, they may not become involved in
looking for it and/or assessing patients for it, which would,
in turn, limit women from disclosing their history of abuse
(Usta & Taleb, 2014).
Rose etal. consider the assessment of GBV as one of
the primary responsibilities of healthcare providers. They
explain how disclosure will become easier for patients if
care providers accept this responsibility and directly ask
patients about any history of abuse. According to other
studies,healthcare providers should be encouraged to be
vigilant about the signs and symptoms of violence and
engage in direct questioning while maintaining a support-
ive and secure environment (Doran & Hutchinson, 2017;
Rose etal., 2011).
The healthcare providers in this study stated that they had
not received specific training on GBV and felt they did not
have enough knowledge to address it adequately. Therefore,
they insisted on the crucial role of training and clarification
of their practice scope. Training programs need to highlight
the critical role of perinatal care providers regarding GBV
assessment and intervention (Doran & Hutchinson, 2017).
Our participants emphasized the role of empathy, asking
questions and supportive interventions on the willingness
of survivors to break their silence. Although screening may
increase the rate of GBV identification during perinatal
care, asking about the history of violence without further
intervention and support does not protect women from more
violence (Bair-Merritt etal., 2014). Therefore, effective and
appropriate response and intervention towards women’s
disclosure of GBV is the primary concern. According to
a systematic review, although results of the interventions
after disclosure in the included studies were heterogeneous,
the majority of interventions demonstrated some benefits to
survivors (Bair-Merritt etal., 2014).
Survivors preferred to access consistent perinatal care
providers during their pregnancy and believed rotating care
providers disrupted relationships during perinatal care. Hav-
ing access to continuing care from the same personal phy-
sician is highly valued by family physicians and patients
(College of Family Physicians of Canada, 2012). In line with
our findings, other studies show that superficial relationships
with care providers and fear of not being believed were
among the main reasons for nondisclosure among survivors
(Amin etal., 2017).
Finally, study participants suggested that looking at GBV
through a multicultural lens without judgment would likely
lead to more disclosure. Evidence confirms this finding by
emphasizing the importance of considering the culture and
sociopolitical dynamics of ethnic variation while approach-
ing GBV (Kasturirangan etal., 2004).
Provide support for survivors and care providers: Our
data suggest that both perinatal healthcare providers and
survivors of GBV need additional supports from the health-
care system. Clinicians talked about needing training, less
workload, and fees for providing care for GBV. Issues such
as lack of time, insufficient skills, and feeling overwhelmed
by the phenomenon’s emotional nature were mentioned by
healthcare providers as barriers to adequately addressing
GBV. Our findings have similarities with studies that refer
to issues such as lack of time and insufficient skills as hur-
dles against disclosure. Our study identifies the facilitators to
identification and disclosure as receiving information, hav-
ing access to screening tools, skills training, and receiving
support from the health care system that is equipped to man-
age GBV(Hegarty etal., 2020; Tarzia etal., 2020). Survivors
also emphasized the need for care providers to spend more
time listening to their stories; thus, decreasing the workload
of health professionals and improving compensation for this
type of work could create an extra time and give them the
opportunity to address violence and provide conditions for
disclosure (Hegarty etal., 2020; Tarzia etal., 2020).
Concerning work overload and lack of time, some exist-
ing evidence-based models of GBV intervention are com-
patible with busy health care settings. Nevertheless, none of
the created interventions are primarily physician-delivered,
and all are designed to be applied within the context of a
multidisciplinary care team. (Bair-Merritt etal., 2014).
Moreover, transforming primary care systems into Patient-
Centered Medical Homes (PCMHs) could be beneficial in
the identification of GBV and administration of appropriate
interventions. In this regard, adding members responsible
for responding to GBV in multidisciplinary teams could
be helpful. Integrating interventions into primary care is
580 Journal of Family Violence (2023) 38:571–583
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1 3
another model. In this model, once GBV is identified, the
survivor would be referred to an outside GBV advocate
(Bair-Merritt etal., 2014).
Furthermore, based on perinatal health care providers expe-
rience, facilitators to identification and disclosure are receiving
information, having access to screening tools, skills training, and
receiving support from the health care system that is equipped
to manage GBV(Hegarty etal., 2020; Tarzia etal., 2020). In
line with our study’s findings, “Being supported by the health
system” was one of the main themes that emerged from a meta-
synthesis related to the readiness of care providers to address
violence and abuse (Hegarty etal., 2020). Moreover, in their
study, Beynon etal. confirmed that a supportive work environ-
ment is a valuable facilitator for the identification of GBV by
care providers and would encourage survivors to disclose (Bey-
non etal., 2012).
Although visits to primary care providers and most hos-
pital services are insured services in Canada, the study
participants frequently mentioned the need for insurance
coverage for counselling. It was clear from their experi-
ence that survivors would show more willingness to dis-
close if the counselling services were covered by insur-
ance. Facilitating quick and easy access to counselling and
providing the opportunity to discuss individual situations
are important supportive strategies that would encourage
survivors to talk about the history of GBV (Beynon etal.,
2012).
Recommendations It seems that raising public awareness
regarding GBV and the importance of disclosure and seek-
ing help during the perinatal period might be enhanced
through providing more information in public places, clinics,
hospitals, and media. Also, informed and skillful health care
providers who are aware of their critical role regarding GBV
and are not overwhelmed by work overload would provide
an atmosphere through which survivors feel comfortable
disclosing. Knowledgeable and skillful perinatal care pro-
viders would have higher self-confidence for being involved
in the identification of GBV. This goal would be attainable
by paying more attention to GBV in schools and continuing
education. Not only should healthcare providers be aware of
their essential role concerning GBV, but also survivors and
the community should know that this is in the realm of care
providers’ practice. Moreover, campaigns that support the
equal rights of men and women need to be strengthened in
society. Women who break the silence and talk about their
experiences should receive meaningful support. The health-
care system needs to reform from the inside, take practical
steps regarding GBV, and be more equipped and prepared
to support both women and care providers.
Limitations As this study took place over the course of
the COVID-19 pandemic, this meant that in the middle of
the project, our interviews shifted from in-person to tel-
ephone semi-structured interviews. Self-selection to the
study is another limitation of the study, and the results are
context-dependent to the Canadian healthcare system. The
findings of this study are specific to the Canadian context.
Also, the generalizability of the findings is limited because
we excluded mothers who were current drug users or had
major mental health problems like schizophrenia and major
depression. We didn’t talk with health leaders in this study,
and their perspectives regarding the facilitators of disclosure
were not included in this study.
Conclusion This study suggests that the healthcare system
needs to change its approach towards GBV. Care needs to
be offered relationally and in safe conditions for survivors
to feel comfortable to disclose and seek help. Clinical edu-
cation and the healthcare system should invest in training
and raising awareness regarding GBV, support restructuring
the care encounter to build trust between survivors and care
providers, and expand the relationship-based approach to
healthcare. Perinatal healthcare providers need to be aware
of their role and responsibility regarding GBV identifica-
tion, know how to provide support, and be appropriately
compensated for this work.
Acknowledgements The researchers would like to express their grati-
tude to all women and health care providers who participated in this
research and provided us with their valuable experiences. We appreci-
ate the Women’s Health Research Institute, Perinatal Services BC, and
UBC for their support in the process of doing this project. Also, we
thank Lily Harrison, Shahriar Jahanbani, and Jacqueline Seppelt for
helping us as volunteers in this project.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
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