Monthly Archives: May 2019

Foetal Death and Domestic Violence

Nasty thought, right enough…

Why am I always writing about such nasty subjects? It’s because those whose stories I deconstruct set the agenda. Sorry, but there it is. I have a new woozle for you.

Acknowledgement: Thanks to Douglas for a number of the links used below.

In January 2019, the Royal College of Midwives’ web site contained this statement,

Nearly 30% of abuse starts in pregnancy and 40% to 60% of women experiencing domestic abuse are abused when they are expecting a baby. Domestic violence has overtaken gestational diabetes and pre-eclampsia as the leading cause of foetal death.’

It was on this page: The page has now been taken down but the above statements by the Royal College of Midwives can be retrieved via the WaybackMachine, here. The page appeared in the context of a so-called “16 day domestic violence campaign”. This is a campaign which is promulgated by UN Women and supported by the World Health Organisation, amongst others.

The idea that pregnant women are being so battered by violent men that they are loosing their babies in a sort of monstrous epidemic is extremely disconcerting. The mental image it conjures presents men as surpassingly vile. There is no doubt that it happens. There is scarcely any nasty thing one can dream up which does not actually happen. But the question is: at what frequency? Is domestic violence really the leading cause of foetal death?

The same statement, specifically that ‘domestic violence has overtaken gestational diabetes and pre-eclampsia as the leading cause of foetal death’ is made by Nottinghamshire Women’s Aid. (You remember them? See here, for example).

What does the statement say, exactly? Does it mean that domestic violence is the leading cause of foetal death, or does it  mean that domestic violence causes more foetal deaths than gestational diabetes and pre-eclampsia? The difference between the two may not be very great as Weissgerber and Mudd tell us in ‘Preeclampsia and Diabetes’ that,

‘Preeclampsia is a leading cause of maternal and fetal morbidity and mortality. In developed countries, this syndrome affects 2-7% of pregnancies in non-diabetic women. Type 1 diabetes, type 2 diabetes and gestational diabetes further increase preeclampsia risk.

Consequently, it seems clear that the Royal College of Midwives’ statement was referring to a common perception of gestational diabetes and pre-eclampsia as leading causes of foetal death, and hence the claim that these have been overtaken by foetal deaths due to domestic violence is a claim that domestic violence is a leading cause, and arguably the leading cause, of foetal death.

The stronger claim is made unequivocally on the Henry Smith Charity site in relation to their funding of Nottinghamshire Women’s Aid. The statement here is,

Domestic violence is now the leading cause of foetal death.’

[Though not my present concern, Henry Smith’s grant of £135,700 to Nottinghamshire Women’s Aid was for the purpose of funding IDVAs (Independent Domestic Violence Advisors) to be placed within maternity units in Nottinghamshire. You may have your own view regarding the motivation behind this. I wonder whether the Henry Smith Charity have been misled regarding the risk to pregnant women of domestic violence].

As its source the Henry Smith web page cites, “Information taken from “A Cry for Health: Why we must invest in domestic abuse services in hospitals (2016)” produced by SafeLives (see the note on Safelives at the end of this post). This link refers to Safelives’ page IDVAs in Maternity Units which quotes the published source as,

Friend. J (1998), ‘Responding to violence against women: a specialist’s role’, Editorial, Hospital Medicine, September, Vol 59, No. 9, pp 98-99

I suspect this paper is not available on the internet. One would need to find a hardcopy in the dusty archive of some library, I expect (the way one used to find anything in the days before the internet). However, the use of the word “now” in the above quote is weird for a source from 1998.

The Royal College of Midwives site contained this footnote,

Domestic violence has overtaken gestational diabetes and pre-eclampsia as the leading cause of foetal death. Pregnant women are more likely to have multiple sites of injury and to be struck on the abdomen. Midwives can play a crucial role in the identification of women and families at risk of domestic abuse. Midwives should look for unexplained injuries in their patients, as well as to histories of preterm labour and birth, foetal injuries or death, abruption and unexplained maternal bleeding, which may require further exploration.

…and it provides a link to a source, namely ‘Domestic violence and pregnancy’ by Gillian Mezey and Susan Bewley, BJOG: An International Journal of Obstetrics & Gynaecology, 104 (5), 528–531, May 1997, available online here. Like the paper by Friend, it is over twenty years old, yet there is a great deal of far more recent information on foetal death, as we shall see. But worse, this paper provides no support for the claim that domestic violence is the leading cause of foetal death, nor for the weaker claim that domestic violence has overtaken gestational diabetes and pre-eclampsia as a leading cause of foetal death.. The nearest it comes is this,

‘It is difficult to estimate the prevalence of domestic violence in pregnant women. However, it appears to be a more frequent occurrence than other recognised obstetric complications such as pre-eclampsia, placenta praevia, twins or gestational diabetes, for which women are routinely screened.’

There are two problems with this statement. The first is that it is impossibly vague: it makes no definite statement (“appears to be”?). But worse, it does not make even the vaguest statement about the foetal death rate due to domestic violence, either in comparison with that due to pre-eclampsia and gestational diabetes, or in any other terms. Nor does the rest of the paper. The paper does contain some data on the frequency of domestic violence, but gives us no quantitative information at all on foetal death rates. One is very wary about domestic violence prevalence data, since such data is meaningless without a detailed account of how the data was collected. Being nominally the victim of domestic violence says nothing very much about risk of foetal death, as we shall see.

As one example from Mezey and Bewley: ‘Helton et al assessed 290 healthy pregnant women in antenatal clinics of whom 8% reported bartering during the current pregnancy’. I assume “bartering” should be “battering”. But given that all these were “healthy pregnant women” what does this tells us about foetal death rate due to domestic violence? Nothing at all, except that whatever domestic violence had occurred in these cases did not cause foetal death.

Finally, the London Safeguarding Children Board, in their guidance on domestic abuse, make this statement,

30% of domestic abuse begins or escalates during pregnancy and it has been identified as a prime cause of miscarriage or still-birth

They also cite 1997 references by Mezey, Bewley and Friend, together with a ‘Report on confidential enquiries into maternal deaths in the United Kingdom’, an update of which I shall examine below and also fails to support the claim being made.

In short, this is looking like a typical feminist woozle. A striking, and most alarming, claim turns out to have dubious provenance when one chases down the sources.  I had my suspicions back in January. I have finally found some time to do a little research.

Studies define foetal death as death of the foetus in-uterus subject to a certain minimum of gestation, for which different studies variously use 20 weeks, 22 weeks or 24 weeks. Hence, early miscarriage, before 20 weeks, is not counted. “Stillbirth” is subject to a similar minimum time limit on gestation (24 weeks in the UK) and need not imply delivery at full term.

A 2010 report from the UK’s Royal College of Obstetricians and Gynaecologists, ‘Late Intrauterine Fetal Death and Stillbirth’ estimates that 1 in 200 babies are born dead, there having being 4,037 stillbirths in the UK and Crown Dependencies in 2007, at a rate of 5.2 per 1000 total births. (A smaller adjusted rate is mentioned, 3.9 per 1000, but I am unaware of the nature of the adjustment).

For comparison, in 2017 there were 679,100 live births in England & Wales and in the same year there were 197,533 abortions. Only 2% of these abortions were due to foetal abnormalities. Consequently foetal deaths and stillbirths from all causes after 24 weeks are tiny in number compared with the volume of elective abortions (the former is less than 2% of the latter). Do recall that in 2016, the CEO of the Royal College of Midwives, Cathy Warwick, came out in favour of ending the time limit for abortions entirely.

Let’s try to get a handle on how many foetal deaths are actually caused by domestic violence. The Royal College of Obstetricians and Gynaecologists report ‘Late Intrauterine Fetal Death and Stillbirth’ does not mention domestic violence, nor any other form of trauma explicitly, but it does include this statement,

HM Coroner does not normally have jurisdiction over stillbirth, even if the cause of death is not known, but contact should be made for an apparently fresh stillbirth not attended by a healthcare professional. HM Coroner also has discretion to be involved if the death followed a criminal act such as common assault and can then request for any postmortem to be expedited. Twenty-one stillbirths were referred to HM Coroner Services for England and Wales in 2007 and 13 in 2008. If there is suspicion of actions taken deliberately to cause a stillbirth, the police service should be contacted.’

The figures of 21 and 13 mentioned are not necessarily all related to suspect domestic abuse, but they do represent upper bounds to the number of domestic abuse induced foetal deaths which were brought to the attention of the Coroner in 2007 and 2008. These figures are about 0.5% and 0.3% of all stillbirths/foetal deaths.

A 2011 article in The Lancet, ‘Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis’ by Vicki Flenady et al, trawled 6,963 studies and selected 96 for meta-analysis with the aim of identifying priority areas for stillbirth prevention relevant to high-income countries. The factors most frequently reported were identified and selected according to whether they could potentially be reduced through lifestyle or medical intervention. It is not clear whether this selection methodology would exclude domestic violence (though, logically, it should not). However, the meta-analysis made no mention whatsoever of domestic violence, or assault more generally, as a factor related to stillbirth/foetal death. Their conclusions were as follows. Maternal overweight and obesity was the highest ranked modifiable risk factor identified. Advanced maternal age (>35 years) and maternal smoking were the next two most significant identified factors. In disadvantaged populations maternal smoking could contribute to 20% of stillbirths. Primiparity contributes to around 15% of stillbirths. Of the pregnancy disorders, small foetal size and placental abruption are the highest risk factors. Pre-existing diabetes and hypertension disorders also remain important contributors to stillbirth in high income countries.

A report from the US Department of Health and Human Services, ‘Cause of Fetal Death: Data From the Fetal Death Report, 2014’ by Donna Hoyert and Elizabeth Gregory, collected data on foetal deaths after 20 weeks gestation from a reporting area of 35 states, New York City, and the District of Columbia, an area representing 66% of foetal deaths in the United States. They found a foetal death rate of 6.1 per 1000 live births. Included in the list of causes were accidents (unintended injuries) and assault (homicide). Of the 15,840 foetal deaths recorded in the study, only one was attributed to an accident and none to assault (see Table 1 of the paper).  

However, 30% of the identified foetal deaths had no known attributable cause. Could a large volume of foetal deaths due to assault be hiding within this “unknown” category? It is impossible to be certain, but it seems unlikely. Several hundreds of the “unknown cause” cases were subject to autopsies and detailed histological and placental examination. I do not know how likely such examinations are to identify trauma as the cause, but if trauma were very common one might expect a positive identification in rather more cases than none. In addition, where the assigned proximate cause was, say, abruption (placental detachment) or unexplained bleeding, it is not clear whether the attempt was made in this US Department of Health study to identify a root cause, such as accident or assault or other trauma.

There are many other sources which provide a breakdown of the major causes of foetal death. A large programme supported by the US National Institute of Child Health and Development, the ‘Stillbirth Collaborative Research Network’ examined more than 500 stillbirths that occurred in 59 medical centers around the United States over two and a half years. In almost one-quarter of these cases, the researchers could not determine a probable or even a possible cause of death. Also, many of the stillbirths had more than one likely cause. Where identified, the causes of stillbirth are listed below in order from most common to least common:-

  • Pregnancy complications including preterm labour, pregnancy with twins or triplets, and placental abruption (one in three stillbirths);
  • Placenta problems, e.g., insufficient blood flow to the placenta (almost one in four stillbirths);
  • Birth defects, e.g., foetal genetic abnormality or structural defect (one in ten stillbirths);
  • Infection (one in ten stillbirths);
  • Umbilical cord problems, e.g., the cord can get knotted or squeezed, cutting off oxygen to the developing fetus (one in ten stillbirths);
  • High blood pressure disorders, including preeclampsia (one in ten stillbirths);
  • Mother’s health complications, including diabetes (less than one in ten stillbirths)

The study also notes the increased risk due to financial, emotional or other personal stress, as well as that due to smoking tobacco or marijuana, taking prescription painkillers or using illegal drugs. Domestic violence per se is not explicitly mentioned, though it is possible, as noted before, that assault trauma could be lurking behind some of the stated medical conditions, e.g, abruption, or in the “unknown” category. However, most of the above categories are not consistent with trauma.

A large meta-analysis which concentrated exclusively on trauma to pregnant women was ‘Traumatic injuries to the pregnant patient: a critical literature review’ by Petrone et al, in the European Journal of Trauma and Emergency Surgery, 2017. The review identified that traffic accidents were the most common cause of trauma injury to pregnant women, followed by falls (usually from standing, not from height). Assault is third in order of frequency as regards trauma to pregnant women.

The Petrone et al review takes data from 51 other studies involving some 95,949 cases of trauma to pregnant women across a range of countries, both wealthy and poor nations. Many studies addressed traffic accidents alone. Some addressed falls alone or assault alone. 19 studies considered all causes of trauma and hence provided a measure of the relative incidence of car accidents, falls and assault. Four of these had noticeably higher proportions of assault than the other studies, but these were all from countries which might reasonably be dismissed as not indicative of Western countries, namely Iran, Nigeria and South Africa. The remaining 15 countries provided the following relative incidence of causes of trauma to  pregnant women,

  • Traffic accidents: 44% (median), 48.4% (mean);
  • Falls: 36.5% (median), 32.4% (mean);
  • Assault: 8% (median), 8.4% (mean).

(For the record, the 15 studies which contribute to the above statistics are El Kady, Barre, Sperry, Patteson, Cahill, Cannada, Fischer, Melamed, Periyanayagam, Brookfield, van der Knoop, Shakerian, Weiner, Battaloglu and Distelhorst).

Hence, I conclude that assault is some 5.5 times less frequent than traffic accidents as a cause of trauma to pregnant women.

Petrione et al note that traffic accidents are not only the most common cause of trauma to pregnant women “but also the most life-threatening of mechanisms on injury”.

Where the studies used by Petrone et al gave data on foetal deaths, the percentage of foetal deaths in the trauma cases studied are listed in Petrone’s Table 3. Five studies included cases of assault and also provided a percentage of cases which led to foetal death. These were due to El Kady, Meuleners, Melamed, Shakerian and Distelhorst. In four of these, 1% of cases resulted in foetal death, and in the last study it was 2%. A further study (Nannini) did not appear in Petrone’s Table 3 but the source seemed to indicate that none of the cases of that reference led to foetal death. In four of these studies an overwhelming majority of the cases related to traffic accidents and falls, rather than domestic violence. Because Petrone et al note that traffic accidents are more likely to be fatal than assault, we can conclude that assault trauma to pregnant women results in foetal death in less than 1% of cases.

Armed with the above data we can now do a simple calculation. In 2017 there were, in round numbers, 171,000 casualties of road traffic accidents in Great Britain, see here. (About 1% of these were fatal). These casualties could be to persons of any age. So, dividing by the entire population of GB gives an incidence of traffic accident injury of 0.26% per year. There are, again in round numbers, about 760,000 pregnant women in the UK. Assuming pregnant women are no more or less likely to be involved in a car accident as anyone else, this suggests that about 2,000 pregnant women will be involved in such accidents per year in the UK.

But we have already seen from Petrone et al that assault is some 5.5 times less frequent than traffic accidents as a cause of trauma to pregnant women. Hence, I conclude that the number of pregnant women experiencing assault trauma per year in the UK is about 364. Finally, the proportion of these which result in foetal death is not more than 1%. I conclude that the number of foetal deaths per year in the UK due to assault is not more than about 4.

This very small number is consistent with the earlier reviewed journal papers on foetal death which either fail to mention assault or else indicate that there are no foetal deaths due to assault. However, one should add to this the number of women homicide victims who happened to be pregnant at the time, and the baby was lost.

In that context, as a final piece of evidence, I cite ‘The Seventh Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom: Saving Mothers’ Lives’ (December 2007). This is an update on the series of reports cited by the London Safeguarding Children Board. It is concerned with deaths of women associated with maternity/pregnancy. It is mostly concerned with medical causes. However, there is a section on domestic violence which includes the following, 

During the three years 2003-05, 70 of the women who died from all causes had features of domestic abuse…..For the nineteen women who were murdered the abuse was fatal…..In the opinion of many assessors the death of another woman who died from obstetric haemorrhage was most likely directly related to the violence her partner had inflicted on her body.’

The report adds, ‘there are undoubtedly other deaths that have occurred and not been reported to this Enquiry so this is a minimum figure’. That’s a reasonable proviso to make, but the fact remains that the identified number of pregnant women who were homicide victims in the UK was 7 per year.

In Conclusion

The claims made by Safelives, by Nottinghamshire Women’s Aid, by the London Safeguarding Children Board and by the Royal College of Midwives, that domestic violence is a leading cause – or the leading cause – of foetal death, are unsupported by evidence and almost certainly false. Available information appears to indicate that the annual number of foetal deaths in the UK attributable to domestic violence is unlikely to be much above single digits. This compares with a total of around 4,000 stillbirths/foetal deaths per year in the UK. Domestic violence appears to be the cause of less than 0.5% of foetal deaths (perhaps 0.25%) and is thus very far from being a leading cause.  

The claim made by the above organisations is a woozle of the worst kind. In the case of the Royal College of Midwives this is particularly reprehensible as the matter is within their professional area of expertise.

Why do these feminist organisations promulgate these untruths? The domestic violence industry (Safelives, Women’s Aid and the Safeguarding authorities) do it because they profit from a narrative which talks-up domestic violence and reinforces the need for their services. All feminist organisations, including the Royal College of Midwives, partake of the incessant vilifying of men to bolster their preferred focus of attention. The spectre of men as an ever present danger to women and children is a well trodden path to the realisation of the principal feminist objective of ejecting men from the family via the leverage it provides in the family courts.

They do it because they can, because it furthers their agenda, and because our society permits even professional bodies to lie with impunity, without any social disapprobation and without any recognition that their narratives are socially corrosive.

Appendix: Safelives

SafeLives (previously known as CAADA) run the courses which are required to qualify you as an IDVA (Independent Domestic Violence Advisor). SafeLives also produce the checklist which is used to identify if someone is at serious risk from domestic violence. This checklist is used by many authorities to decide whether to refer someone to a MARAC (Multi-Agency Risk Assessment Conference). This is a panel with membership from various agencies (police, probation service, social workers, etc., and almost always an IDVA). Hence, Safelives have a controlling hand in the DV industry. MARAC referrals are made using a SafeLives procedure, with advice from SafeLives trained ‘experts’. SafeLives are also responsible for the Quality Assurance of the MARAC process. As a result of their particular slant on things, 95% of referrals to MARAC are women. Some people (including MPs) use this to claim that 95% of victims of DV are women. In truth, it only means that 95% of those successfully running the gauntlet of a feminist procedure, operated by feminists, are women. Expecting SafeLives to operate a gender neutral DV policy would be rather like expecting Hamas to play nicely with Israel.