Nordic cooperation supports screening for domestic violence in the first 1000 days

Pregnancy and the first years of life are an important window of opportunity for screening for domestic and honour-related violence. In Sweden, systematic screening during pregnancy was initiated in 2008, and now all the Nordic countries have national guidelines on screening for domestic violence in the first 1000 days.

Domestic violence is a public health problem that have vast physical, psychological, social, and economic consequences for those exposed, as well as for children witnessing the violence. Being witness to violence against the parent or caregiver is child abuse in itself. Children who witness violence at home can be just as affected as if they themselves were exposed to violence, and even when children do not directly witness violence, they may be aware that the violence is occurring which may have vast consequences both on short and long term.(1, 2)

Research also shows that pregnancy and starting a family can trigger or exacerbate domestic violence, making it crucial to detect these cases.

A situation analysis published in 2019 showed that while all countries in their prenatal and child healthcare emphasised the importance of early detection of risk factors such as violence, this was not always implemented in a systematic manner using validated screening instruments.

With Denmark’s new guidelines all Nordic countries now have national recommendations or guidelines on screening for domestic violence, and some countries also have guidelines on honour-related violence.

The first 1000 days – a window of opportunity

Violence can escalate or deteriorate during pregnancy and the first year’s with a little child. The first 1000 days is a window of opportunity to talk about domestic violence. Health personnel in prenatal care and public health nursing have an opportunity to introduce discussions about family conditions, conflict management, and violence. Especially regarding honour-related violence, healthcare professionals have a unique opportunity to detect and respond to violence at an early stage.

When healthcare professionals have specific knowledge regarding violence and what signs of violence may look like, identifying violence in clinical situations becomes easier and more likely. Asking about violence systematically and in different ways can start a process of recognition in the individual and contribute to action.

There must be interventions to refer to, thus making healthcare professionals more likely to ask about domestic violence. Furthermore, local and regional action plans is important when violence is detected.

New initiative in Denmark on screening

In May 2024, the Danish Health Authority, in collaboration with the Danish Agency for International Recruitment and Integration, published National recommendations to prevent and detect domestic violence during pregnancy and the child’s first two years of life. Support and treatment interventions are also being developed.

The initiative is part of the National action plan against intimate partner violence and partner homicide and has a particular focus on honour-related conflicts.

The recommendations are based on the latest national and international research about domestic violence against pregnant women, expecting and new parents; knowledge about citizens with an ethnic minority background and honour-related violence; knowledge about current practices in prenatal care in Denmark; and knowledge about practices of screening for violence in the Nordic countries.

Digital questionnaire assessing abuse

The Danish guidelines are intended to support health professionals and leaders in prenatal care, public health nursing, and general practice on how to work systematically with detection and interventions targeting domestic violence and honour-related violence.

According to the guidelines, a questionnaire is sent electronically to the pregnant woman as soon as the pregnancy is registered. The questionnaire includes questions based on a screening questionnaire named Abuse Assessment Screen (AAS) targeting domestic violence. These guidelines stress the importance of making the woman feel secure and only asking direct questions about violence when the partner or other relative is not present. The oral questions suggested for use in clinical meetings, are based on AAS or Parent Screening Questionnaire (PSQ-S)/ Safe Environment for Every Kid (SEEK).

Suggestions for questions, that are relevant when a partner is present regarding family matters and conflicts are included in the guidelines. Furthermore, asking on several occasions, and in different manners is highlighted. Separate handbooks with flow charts and ‘how to’ for midwives, health visitors as well as general practitioners are also available.

Ask when the partner is not present

Today, all the Nordic countries have national guidelines on universal screening for domestic violence in prenatal care and public health nursing. Several of the Nordic countries also have national registers to collect data.

All Nordic countries now recommend that the pregnant woman should only be asked about domestic violence when the partner is not present. This is according to the WHO- recommendations, that state that screening for domestic violence should only be carried out in a confidential and safe space when the pregnant person, parent or partner is unaccompanied. Therefore, a specific time for the screening for domestic violence is often not recommended, but flexible. In several countries, the midwife and/ or health visitor has an individual consultation with the pregnant person or new mother, at least once during the pregnancy and the child’s first years. In some countries or regions, this is offered to the father/ partner as well.

Overall, experience and research from the other Nordic countries show that the guidelines are a good professional support, and that strengthened knowledge for healthcare professionals result in a broader implementation of guidelines (3,4).

Screening in all the Nordic countries

The National Guidelines in Sweden were implemented already in 2008, with a recommendation to ask all women in prenatal care about their experiences with domestic violence (5,6,7). According to the National pregnancy register, 96 percent of all pregnant persons were asked about domestic violence in 2022 (8). The question of exposure to violence should be asked early in pregnancy in safe and private ways, verbally as it gives the opportunity to ask follow-up questions. To catch those affected, the question should be repeated during pregnancy. In case of identification of violence or threats, all departments have a plan of action, with an additional focus on honour-related violence.

Individually adapted follow-up

Implemented in 2014, Norway’s guidelines include methods to identify violence, with a specific focus on domestic violence and genital mutilation affecting pregnant women (9). Healthcare professionals routinely ask all pregnant women about current and previous experiences with violence using a question guide. The matter is approached at least once in an individual consultation, when the partner is not present.

Healthcare professionals should collaborate with professionals with special expertise regarding violence for specific assessments and security. In health services that take place during the first 1000 days, it is recommended that women, families, and new-borns at risk are offered an individually adapted follow-up.

Investigating the child’s security

In 2019, the Ministry of Social Affairs and Health in Finland published an action plan to prevent violence against children (10). This action plan describes the work within prenatal care, public health nursing, and general practice.

The implementation as well as plans for future national action plans are based upon Istanbul and Lanzarote Conventions for 2022-2025.

It is recommended to use a questionnaire regarding domestic violence when screening, and a support form to explore the child’s security. A specific questionnaire is used when screening among families with an ethnic minority background (10).

Easier to open up about violence

In Iceland national guidelines on evaluating and responding to intimate partner violence in primary care were published in 2012, and these offer examples on how to phrase questions and adapt them to each individual.

Screening for domestic violence, asking about their current or previous experience of violence, will take place at week 16 of pregnancy and nine weeks after birth, without the presence of their partner. It is ensured that the midwife meets the woman at least once alone during the pregnancy.

Many midwives have been trained in using the guidelines in clinical practice to better evaluate the health consequences of violence and trauma for pregnant women, make it easier for them to open up about their experience and ensure referrals to appropriate treatment and resources (11).

The value of Nordic cooperation

These developments are in line with several of the six main policy recommendations (12) that concluded the three-year project concerning the first 1000 days, and specifically the one concerning identifying and responding to risk factors early in life. This is an important step to ensure the safety and well-being of new-borns and their families both in the short and long term.

– Screening for domestic and honour-related violence provides an excellent example of the value of Nordic collaboration in knowledge-based care and services for children and families, says Liv Lyngå von Folsach, Medical Chief Officer at the National Health Authorities in Denmark, and a member of The Nordic Network on the Child’s First 1000 Days.

She is responsible for the Danish knowledge-based National recommendations published in 2024 regarding screening for domestic and honour-related violence as well as support in the first 1000 days.

– The Nordic network aims to strengthen and expand its joint efforts to provide a good life, and a childhood free of violence, for all children and their families in the Nordic countries, says Liv Lyngå von Folsach.