Gender-Based Violence in the Context of Mothering: A Critical Canadian Health Perspective

Abstract

Violence against women is a predominant, human rights violation, globally. Understood as any act of gender-based violence resulting in physical, sexual, or psychological harm or suffering to women, approximately 35% of women experience violence across the lifespan. While violence can be experienced at any age, women of reproductive age suffer the greatest prevalence, underscoring that for many women, experiencing violence or the health and social sequelae, which may follow violence, co-occurs with mothering. Mothering in the context of gender-based violence in Canada is complex and multifaceted. In this article, the interplay among gender-based violence and the childbearing stages of pregnancy, birth, and postpartum are explored using an intersectional lens, including consideration of social disparities and equity-deserving groups. Approaches to address gender-based violence among childbearing women, such as an ecological approach and trauma- and violence-informed care, are discussed as implications for further research and practice.

1. Introduction

Violence against women is the most prevalent human rights violation in the world [1,2]. Understood as any act of gender-based violence resulting in physical, sexual, or psychological harm or suffering to women [3], the World Health Organization (WHO) estimates that 35% of women experience violence in their lifetime [1,2]. While violence can be experienced by women of any age, the greatest prevalence is among women of reproductive age [4]. Given this high lifetime prevalence of violence and that in Canada, an estimated 51.1% of women become mothers [5], the reality is that for many women, experiencing violence co-occurs with mothering. For some women, the violence pre-dates motherhood; for others, being pregnant and/or postpartum will play a role in the onset of abuse [6,7]. The relationship between mothering and gender-based violence (GBV) in Canada is complex and multifaceted. This paper will explore the interplay among GBV and the childbearing stages of pregnancy, birth, and postpartum.

2. Gender-Based Violence and Pregnancy

Pregnancy is a remarkable period in a woman’s life characterized by significant physical, emotional, and hormonal changes. While pregnancy may infer some protection from violence—with the potential of temporary or long-term discontinuation of abuse [8]—population-based studies have revealed that in Canada, an estimated 6% to 11% of women experience violence during pregnancy [9,10,11,12,13]. While research specifically addressing violence among childbearing women is scant, some Canadian-based regional studies have estimated that 6.6% of Ontario women, 5.7% of Saskatchewan women, and 1.2% of British Columbia women have experienced physical violence during pregnancy [12,13,14]. Furthermore, those with an unintended pregnancy are at four times greater risk of abuse than those with a planned pregnancy [15]. Despite the noteworthy prevalence of violence during pregnancy, it is posited that these estimates are lower than actual rates. This underreporting of violence is multifactorial but may be due to recall response bias, cultural tolerance for violence, stigma associated with reporting [8,10], and that many early Canadian studies have focused solely on physical abuse when determining the prevalence of GBV. Regardless of how violence is conceptualized, research has demonstrated consistently that violence pre-pregnancy is the best predictor of violence during pregnancy [6]. Fortunately, conceptualizations of violence have been expanded upon recently, such as the inclusion of forms of abuse specific to being a mother, which occur in the context of pregnancy, intrapartum, postpartum, and throughout motherhood [16]. With the inclusion of considerations specific to childbearing women, the attainment of more fulsome and accurate data for this population will serve to enhance the health and social wellbeing of mothers and their families.

Health Consequences. Women who experience violence during pregnancy are at a higher risk of health complications for both the mother and the developing fetus. Specifically, experiencing violence during the antenatal period is a leading cause of maternal death in Canada [7]. In addition to the risk of maternal death, GBV during pregnancy can lead to a range of pregnancy-related complications, such as premature labor, miscarriage, stillbirth [1,17,18], and intrauterine growth retardation [14]. In addition to negative health consequences, research has also established that experiencing GBV during pregnancy places women at a higher risk of developing depression, anxiety, and post-traumatic stress disorder [19].

Social Consequences. Beyond the negative health consequences to maternal and fetal health, violence experienced during pregnancy also impacts social wellbeing. Most notably, the lack of autonomy which often accompanies experiences of violence can play a significant role in maternal social wellbeing. Women who experience GBV during pregnancy often become socially isolated, which in turn can also negatively affect mental health and wellbeing [20]. For example, a study of mothers in Quebec reported that abusive partners controlled and coerced them—limiting their freedom of movement and action and thus limiting their social connections [16]. This lack of autonomy has been reported in Canadian studies as a key barrier for women in accessing healthcare and other support services [21,22,23]. This lack of autonomy alongside social isolation is associated with challenges such as reduced access to healthcare services, loneliness, and maternal stress. Given the importance of early and regular prenatal care for optimal maternal and fetal health outcomes [24], these barriers to care can lead to more severe negative outcomes, leading to maternal and fetal morbidity and/or death [25].

3. Gender-Based Violence and Birth

The relationship between GBV and birth outcomes is complex, and various intersecting sociodemographic/economic factors and birth context have been shown to influence these outcomes [26]. Among these factors, GBV can play a significant role in risks associated with maternal and fetal/newborn health during the intrapartum period. Women who experience violence are at higher risk of complications of labor and birth, such as preterm birth, having infants with low birth weight, [17,27,28,29], and maternal stress [20]. For example, a study of 4750 women in British Columbia, Canada, found that women who experienced violence during pregnancy were at greater risk of antepartum hemorrhage and perinatal death compared to women who did not experience violence [14]. Beyond the impact on the mother, birth complications for infants have also been reported and include higher rates of NICU admissions and infant mortality [17,27,29].

Maternal and Fetal/Infant Health Outcomes. Gender-based violence against pregnant women has been associated with several negative birth outcomes, such as preterm birth; low birth weight; complications during delivery, such as antepartum hemorrhage; and neonatal intensive care unit (NICU) admissions [17,27,29]. Several studies, reviews, and meta-analyses have reported a correlation between exposure to violence and preterm birth, even after controlling for confounding variables [26,27,29,30]. To highlight, a Portuguese hospital-based study of 2660 women found that 24% of mothers with preterm infants had experienced physical abuse versus 8% of mothers with full-term infants. This association was maintained when preterm birth was controlled for confounding variables such as age, sociodemographic factors, and other characteristics contributing to preterm birth [31]. Women who experience physical abuse during pregnancy are at a much greater risk for preterm delivery. Preterm birth is of concern as it can lead to a range of health problems for the newborn, including respiratory distress, neurological problems, and developmental delays. Women who experience GBV during pregnancy are also at higher risk of giving birth to infants with low birth weight [17,27,29,30], which, in turn, can have negative effects on newborn health and development and increased risk of mortality and morbidity.

Maternal Stress. Childbirth, in and of itself, is an extremely stressful experience for many women, especially when this process violates personal expectations and a loss of control over one’s decision making and body [32]. Negative birth experiences impact not only maternal health but also the infant’s health and development well beyond birth [33]. Combined with experiences of GBV and its associated psychological trauma, childbirth can be an extreme form of maternal stress [20], negatively impacting maternal mental health and wellbeing during labor and birth. While often interrelated, in the context of GBV, there are several variables at play that can lead to maternal stress during birth, such as fear of childbirth, lack of a supportive partner, and/or coercive control by an abusive partner.

Fear of childbirth is commonly experienced across all populations of mothers, but with wide variability in prevalence ranging from 5% to 52%, depending upon the population sampled [34]. However, it has been reported that up to 25% of women in violent relationships experience a fear of childbirth [34]. For some women, fearing childbirth can lead to unneeded interventions at birth. To highlight, a literature review by McCourt and colleagues [35] found an increased risk of cesarean sections when mothers reported a fear of childbirth. Psychological and social factors are often implicated in fear of childbirth, such as lack of social support, dissatisfaction with an intimate partner, high daily stressors, and anxiety [34,36]—each of which has a relationship with GBV.

For women experiencing intimate partner violence, not having a supportive partner can impact the experience and outcomes of labor and birth [33]. This lack of a supportive birthing partner has been attributed to the coercive control exerted within violent relationships as well as an erosion of social support for mothers beyond their abusive partners due to social isolation, a common tactic used in abusive relationships. Additionally, abusive partners have been found to undermine mothers’ self-efficacy, which ultimately impacts the birthing process [20]. A recent qualitative study by Levesque and colleagues [16] reported some of the stressful birth experiences by mothers who had abusive partners. According to many of the participants, both physical and psychological violence was experienced during labor; for example, being belittled and mocked when expressing labor pain, receiving death threats, posting non-consensual photos on social media, and strangulation. Beyond direct partner–partner violence, this study also reported structural violence, wherein women were denied their requests to not have their abusive partner present during labor [16]. These poor and stressful conditions by laboring mothers led to considerable stress and a lack of a supportive birth partner [16]. Overall, this heightened maternal stress often results in dissatisfaction with the birthing process, with women experiencing violence being more likely to rate their birth experience as negative compared to mothers who have not experienced violence [34]. Furthermore, beyond dissatisfaction, lack of partner support during labor is linked to numerous intrapartum and postpartum outcomes, such as having a greater need for pain relief, higher levels of anxiety, and poorer breastfeeding outcomes [37].

4. Gender-Based Violence and the Postpartum Period

Early Canadian research reported that women who experienced GBV during pregnancy often also experienced increased violence in the postpartum period [6]. A more recent Canada-based study of over 2000 children found that 11.1% were exposed to intimate partner violence between 6 months and 8 years of age [16]. This prevalence of GBV during the postpartum period is also echoed across global studies. A narrative review reported that while the prevalence of GBV was slightly higher during pregnancy (1.5% to 66.9%), GBV during the postpartum period was 2–58%, with psychological intimate partner violence being the most prevalent form [38].

The postpartum period, also known as the fourth trimester, refers to the phases immediately following childbirth, with the acute phase up to 7 days after the delivery of the placenta up to 6 weeks to 6 months afterward [39]. The postpartum period is a time of immense physical and emotional changes alongside the maternal physiological and anatomical changes of returning to a non-pregnant state. Further, for women who choose to breastfeed, the postpartum period is a time of establishing and adjusting to breastfeeding. The postpartum period brings fluctuations in hormones, coupled with lack of sleep and managing the demands of caring for a newborn; as such, this period often comes with a range of emotions such as mood swings, feelings of joy, sadness, and for some, postpartum depression and/or anxiety [32]. While emotional distress is experienced by many postpartum women, exposure to GBV increases the risk of a major depressive disorder and/or anxiety disorder [40,41], and in turn, has serious consequences for the health and wellbeing of the mother and infant [42].

Postpartum Depression. Currently, studies, reviews, and meta-analyses provide varied descriptions of the relationship between violence and postpartum depression. However, it is understood that exposure to violence results in an imbalance between environmental demands and an individual’s resources, which has been associated with a decrease in resilience, coping, and social support for some women, increasing susceptibility to depression [2]. The variation in findings has been attributed to both the conceptualization of violence (what is defined as violence) as well as the many varied measurement scales and tools used to detect postpartum depression [9]. In a recent systematic review of 33 studies, there was an association reported between violence (physical, emotional, and/or sexual) and the development of symptomology consistent with postpartum depression [40]. Further, a study including 8000 Canadian mothers found that the odds of experiencing postpartum depression were 60% greater among mothers who had experienced physical or sexual violence compared to those who had not experienced violence [9].

Breastfeeding and Violence. Women who experience GBV during the postpartum period may have difficulty breastfeeding. While Canadian-based studies are sparse, according to data from Statistics Canada [43], women who experience intimate partner violence are less likely to start breastfeeding, are less likely to exclusively breastfeed, and breastfeed for shorter durations than non-abused women. Experiencing GBV at any point across the perinatal period can have significant impacts on women’s decision making around breastfeeding [44]. A recent scoping review of maternal decision making among mothers experiencing intimate partner violence concluded that violence plays a role in suboptimal breastfeeding practices [45]. Specifically, the issue of maternal stress and lack of partner support were identified as key factors contributing to poorer breastfeeding outcomes for women experiencing intimate partner violence.

Mothering. The relationship between trauma and mothering is complex and can vary, depending on the individual’s experiences, the nature of the trauma, and the available support systems. Experiencing trauma, such as GBV, neglect, or other adverse childhood experiences, may carry the effects of that trauma into their mothering role. Trauma can affect emotional regulation, attachment patterns, and interpersonal relationships, which can influence mothering behaviors and subsequent interactions with children. In addition, co-parenting with a current or ex-abusive partner brings additional layers of challenges and complexity. While the body of literature encompassing the intersections of mothering and GBV is scant, evidence suggests that GBV may negatively impact mother’s physical and psychological health, in addition to increasing the risk of impaired childhood development and poorer mental health among the children of those abused [46,47,48].

Women experiencing violence are at greater risk for challenges with bonding and mother–infant attachment compared to their non-exposed counterparts [19]. Trauma-related physiological and psychological symptoms such as hyperarousal, hypervigilance, intrusive thoughts, and emotional numbing can all impact a mother’s ability to parent effectively. These symptoms may lead to difficulties in providing consistent nurturing and attuned care, maintaining healthy boundaries, and managing stress within the mother–child relationship. For example, a study exploring the impact of violence on parenting reported that women experiencing violence needed to emotionally disconnect to survive the violence, and in turn, from this disconnection, they also felt disconnected from their child(ren) [49].

Mothering in the context of GBV is also influenced by the challenge and complexity of having to co-parent with abusive partners and ex-partners. A study by Levesque and colleagues [16] found that women in abusive relationships often reported a lack of partner investment in parenting, resulting in mothers having to do the majority of the parenting. Moreover, women also reported anxiety around parenting with their abusive partners, particularly after leaving the relationship, as they feared not only the violence but also the coercive control tactics that would continue via the interactions required of co-parenting [50].

While trauma can pose challenges to mothering, it is important to note that not all mothers who face trauma will have negative mothering experiences. Protective factors, such as social support, access to mental health services, resilience, and healing from past trauma, can mitigate the impact of GBV on mothering. Furthermore, mothers often report using a variety of protective strategies to mitigate the negative effects of exposure to abuse on their children. Behavioral strategies to keep children safe, such as removing children from violent situations and/or avoiding situations that may lead to violence, have been widely reported [51,52]. Further, emotional strategies employed by mothers to compensate for their abusive partners, including being more nurturing and attentive, actively affirming their children, and spending time with their children, have also been reported [53].

5. Other Considerations

Gender-Based Violence and Equity-Deserving Groups. Equity-deserving groups are social groups that have historically faced systemic disadvantages and discrimination, and, therefore, are considered deserving of equity or fair treatment to address these disparities. These groups often include marginalized communities that have been historically marginalized or oppressed based on characteristics such as race, ethnicity, gender, sexual orientation, disability, socioeconomic status, or religion. Examples of equity-deserving groups may include racial and ethnic minorities, women, LGBTQ+ individuals, people with disabilities, Indigenous communities, religious minorities, and individuals from low socioeconomic backgrounds. A study by Daoud and colleagues [11] found that prevalence rates of abuse for mothers were higher among equity-deserving groups, including mothers of lower socioeconomic status and Indigenous mothers. As an example, in a study of immigrant and refugee women in Canada, it was found that mothers experienced barriers in disclosing abuse and leaving abusive relationships due to cultural contexts [54]. Specifically, mothers reported fear of disapproval by their cultural community, the potential negative impact on their immigration status, and fear of an unfamiliar legal system as key barriers to leaving an abusive relationship [54].

The concept of equity-deserving groups emphasizes the need to rectify systemic injustices and create opportunities for these groups to ensure fair and equal access to resources, rights, and opportunities. It is well documented that equity-deserving groups experience health disparities; however, these disparities are further compounded when individuals are part of more than one equity-deserving group [55]. Intersecting forms of oppression, racism, sexism, ableism, or homophobia can have a significant impact on health by creating complex and compounded challenges for individuals and communities. When individuals experience multiple forms of oppression simultaneously, the health, social, and political effects can be profoundly detrimental [55].

When considering equity-deserving groups, understanding intersectionality or the reality that experiences of discrimination and oppression can be layered based on the social categories to which individuals belong is paramount [56]. While Crenshaw’s initial work in intersectionality revolved around employment and black women, it was later adopted by the GBV movement as differences in the experiences of violence emerged dependent on social categorizations [57]. The benefit of using intersectionality in understanding experiences of violence is that we can observe the differential effects of violence based on social location and understand that the effects of intersecting forms of oppression are cumulative. For instance, discrimination, stigma, and social exclusion can lead to increased stress, anxiety, depression, and other mental health challenges [55]. Marginalized individuals may face barriers to accessing quality healthcare, leading to delayed diagnoses, inadequate treatment, and poorer health outcomes. In addition, intersecting forms of oppression can affect access to healthcare services and the quality of care received [55]. For example, a scoping review on maternal health found that immigrant and refugee women in Canada were at higher risk of miscarriage than non-immigrant and refugee women [21]. It was identified that language barriers served as a significant barrier to care for these women, who were less likely to receive prenatal care compared to their non-migrant counterparts [21].

Beyond health consequences, there are social consequences of oppression that are far- reaching and can have profound effects on individuals, communities, and society. Specifically, oppression perpetuates inequality by marginalizing and excluding certain groups. This leads to disparities in areas such as education, employment, housing, healthcare, and political participation. The reality is that violence not only impacts mothers but also permeates communities, organizations, and social structures. As such, when we are examining the impacts of violence, we need to understand not only the lived experience but also the structural underpinnings of societies and communities and how both are located and derived from history, social relationships, and structures of power, which can serve to perpetuate violence [58,59] For example, a Canadian study [22] found that experiencing multiple pandemics, including the GBV and racism pandemic, simultaneously amplified existing systemic and structural inequities for women, including inadequate housing and a lack of funding for the GBV sector. Oppression often creates divisions within society, pitting privileged groups against marginalized groups. This can lead to social tension, resentment, and conflict as marginalized groups fight for their rights and challenge the existing power structures.

When people are systematically denied opportunities based on their identity, talents, or abilities, it limits their ability to contribute fully to society and hinders overall social progress. Oppression reinforces stereotypes and prejudices against marginalized groups. Negative stereotypes are perpetuated, leading to bias, discrimination, and prejudice in interpersonal interactions and institutional practices. Oppression often results in the social exclusion and isolation of marginalized groups [60], with barriers to social integration, ostracism, and being denied a sense of belonging and acceptance within broader society. Oppression erodes social cohesion by creating divisions and undermining trust among different groups within society. This can hinder collective action, collaboration, and solidarity necessary for addressing broader social challenges. Oppression suppresses diverse perspectives, experiences, and contributions. When certain groups are oppressed, their unique insights, talents, and creativity are stifled, limiting society’s ability to innovate and solve complex problems.

Turning Points. A mother’s decision to leave an abusive relationship or turning point has been widely studied, focusing on the events that preceded or initiated the leaving process. Turning points are largely individual and can include ‘hitting rock bottom’, relationship fatigue, a broken bond with the abuser, increased fear for safety, and mothering. However, mothering in relation to turning points is not as well understood [61]. For mothers experiencing violence in Canada, turning points may vary depending on individual circumstances. Some evidence suggests that becoming a mother can act as a turning point, while other studies have found the turning point occurs in the mothering journey, resulting from factors such as increased fear for the child’s safety or desire to be a better mother [61]. Secco and colleagues’ [62] theory of awakened maternal identity, a psychological and sociological concept that describes how a mother develops a strong and positive sense of herself in the context of motherhood, offers a first insight into turning points among mothers. Secco and colleagues [62] posit that the turning point occurs when a mother transitions from a diminished maternal identity characterized by weakened maternal abilities and interrupted mother–infant bonds to an awakened maternal identity when the mothers sense of responsibility is heightened and they feel called to defend and protect their children. It is important to note that this theory emphasizes the importance of societal support and resources for mothers to fully realize their maternal identity. This includes access to healthcare, childcare, and social support, as well as policies that support work–life balance and gender equality. Overall, the theory of awakened maternal identity suggests that motherhood can be a positive and transformative experience that can lead to personal growth and empowerment [62]. By recognizing and supporting the process of maternal identity development, we can promote the wellbeing of mothers and their children as well as contribute to a more equitable and just society.

Turning Points and Children. Leaving a violent relationship can be a challenging and dangerous process for mothers and children, and attaining support is crucial. For example, a study of the role of community support among rural Canadian women leaving abusive relationships reported that women who accessed support from community organizations reported feeling more supported and less isolated [63], which was key in enabling them to leave safely. Before leaving, it is important for mothers to develop a safety plan which includes strategies for mother and child(ren) to stay safe during and after the leaving process. This plan can involve reaching out to friends, family, or community resources for support, securing important documents and resources, and planning for housing and childcare. Beyond the involvement of the community and other support, work by Winfield and colleagues [64] also highlighted the importance of involving children in safety planning. Effective communication of the safety plan with the child, including how the plan would keep them safe from the abuser during and after leaving, is helpful in supporting children to cope with the increased disruptions in their lives during this time of transition.

Turning Points and Access to Children. Women who are experiencing violence face real concerns and subsequent stress related to custody and access to their children if they leave the relationship. Co-parenting through divorce from an abusive partner can be emotionally taxing for both women and their children. For example, mothers will often report that their children return from visits with their abusive ex-partner feeling stressed, unsettled, and insecure [49]. Unfortunately, these difficulties experienced by mothers are occurring more frequently due to court orders shifting away from single parenting and toward shared parenting, wherein children spend at least 40% of their time with each parent [50]. This is particularly problematic, as shared parenting arrangements are often used by former abusive partners as a way to maintain communication and thus to continue perpetrating violence against their former partner. To highlight, a study using in-depth interviews among 20 Canadian women found that mothers’ shared parenting arrangements were a ‘constant balancing act’ requiring women to manage the violence while having to maintain contact with their abusive partner [51]. In addition, research has demonstrated that it is difficult for mothers to ensure their child(ren)’s safety while adhering to court orders [50].

Within the context of the criminal justice system, it is important to understand that violence crosses legal jurisdictions, including family and criminal law, creating increased complexity for both the legal system as well as those navigating it. Within the criminal law system, protection orders have been studied globally, exploring the impact on keeping mothers and children safe [65]. However, in a synthesis of the effects of violence protection orders, it was found that their utility ranges for mothers based on their expectations and experiences. To that end, while protection orders are a legal tool available to mothers, the reality is that mothers are required to navigate the legal system, which is complex and inadequately acknowledges the context and consequences of violence [65].

6. Approaches to Address Gender-Based Violence

Canadian mothers have identified the need to have both their practical needs met alongside an integrated approach to social, health, and political needs addressed to best support them experiencing GBV [58]. The integration of intersectionality and the GBV movement has borne a three-fold approach to ending violence inclusive of advocacy, organization, and empowering survivors [66]. Through this approach, GBV solutions call for an understanding of the causes, interplay, and outcomes of gender inequities and violence, and there is a need to employ an ecological, trauma- and violence-informed, responsive, and access-based approach to support mothers.

Ecological Approach. The WHO has called for an ecological approach to understanding the ‘roots of violence’ to reduce gender inequities and GBV [67]. The ecological approach to reducing gender inequities and GBV recognizes that these issues are deeply rooted in social, cultural, economic, and political contexts. It emphasizes the importance of addressing multiple levels of influence to create lasting change. This model identifies six levels that influence gender inequities and GBV [67]. At the individual level, interventions focus on changing attitudes, beliefs, and behaviors that contribute to gender inequities and violence. This includes promoting gender equality, challenging harmful gender norms and stereotypes, and promoting healthy relationships and consent education. At the intrapersonal level, interventions aim to improve communication and relationship skills as well as promote gender equitable and non-violent relationships. This involves engaging with families, communities, and peer networks to promote positive social norms, respectful communication, and support systems for survivors [67]. At the community level, efforts are made to engage with and mobilize communities to address gender inequities and violence. This includes community education, awareness campaigns, and the establishment of community-based support services. It also involves working with community leaders, organizations, and institutions to foster a supportive environment and challenge harmful practices [67]. Interventions at the societal level aim to transform social norms, policies, and institutions to create an environment that is equitable and free from GBV. This involves advocating for gender-responsive laws, policies, and regulations, promoting gender diversity and inclusion in leadership positions, and challenging systemic inequalities that perpetuate gender inequities [67].

On the whole, the ecological approach recognizes the importance of collaboration across different sectors, including government, civil society organizations, academia, and grassroots movements. By working together, these parties can combine their expertise, resources, and influence to create comprehensive and sustainable solutions [67]. The ecological approach is data-driven, meaning, the use of data and research to inform interventions, monitor progress, and evaluate outcomes is prioritized. This includes collecting data on the prevalence of gender inequities and violence, understanding the underlying causes and risk factors, and using evidence-based approaches to guide interventions [68]. By addressing gender inequities and violence using an ecological approach, efforts can be more comprehensive, holistic, and sustainable as the intersectional reality of violence is accounted for with the aim of promoting long-term social change [67].

Trauma- and Violence-Informed Care. Women experiencing abuse often have significant and unique forms of trauma both as an experience and response to violence. As such, there is a need for trauma- and violence-informed and equity-oriented approaches to care [68]. Trauma- and violence-informed care (TVIC) is an approach that recognizes the prevalence and impact of often intersecting forms of trauma and violence in people’s lives and seeks to provide care and ensure structures are sensitive and responsive to their needs [68]. There is evidence to suggest that TVIC can be effective in supporting Canadian mothers experiencing violence. A study conducted in British Columbia found that pregnant women who received care from a TVIC clinic reported higher levels of satisfaction with their care and better outcomes compared to those who received standard care. Women who received TVIC reported feeling more supported and understood and were more likely to disclose experiences of violence [69]. Further, a study by Jackson and colleagues [70] found that TVIC when integrated with cognitive behavioural therapy had a positive effect on preventing or minimizing violence-related mood and anxiety disorders. In sum, TVIC holds promise as an equity-oriented approach to care with the potential to improve the support of and subsequent health and wellbeing of women and children exposed to violence.

Responsive to Needs. It is important that health and social services and interventions are appropriate and sensitive to the needs of mothers experiencing violence, particularly the use (or lack thereof) of screening for violence. The literature surrounding the use of screening is equivocal—with some suggesting that there is the need to screen for violence in order to provide appropriate and sensitive care to mothers experiencing violence, with other studies suggesting the opposite. To highlight, a 2015 Cochrane review found that screening for violence among pregnant women was associated with 4.5-fold increased odds of identifying women exposed to violence [71]. However, other research has found that screening for violence was associated with overall poor maternal and child health and increased child protective services contact when mothers screened positively [72]. In sum, the assessment and identification of GBV remains a controversial issue [2].

Current Canadian standards of healthcare practice support the World Health Organization’s endorsement of using screening for violence in healthcare contexts [68]. For example, professional associations, such as the Registered Nurses’ Association of Ontario, support the practice of screening for violence [73]. Screening in the context of healthcare refers to asking everyone, regardless of why they are seeking care, about their experiences of violence. In clinical settings, this often takes the form of ‘yes/no’ questions, for instance, ‘Have you ever been hit, slapped, or kicked?’ [73]. However, it is critical to keep the impact on care central to this issue of screening for violence. To advance understanding and use of screening, MacMillian and colleagues [74] described the issue with screening as being two-fold. On one hand, many healthcare providers are not comfortable asking questions to screen for violence, and additionally, lack the skills and confidence to intervene appropriately if a woman discloses violence. If providers are not skilled in asking questions about, and responding to disclosures of violence, they have the potential to do harm. The second issue of debate is whether there is sufficient evidence to support that screening improves outcomes. The World Health Organization has concluded that currently, there is insufficient evidence that screening for GBV improves quality of life or health outcomes [67]. The caveat to this side of the debate is that evidence suggests that when programs have planned post-screening protocols and actions, including appropriate training of care providers and appropriate resources to respond to violence, screening may lead to improved health outcomes for women [67,74].

Aside from the practice of screening for violence, it is critical that services are responsive and built upon trusting mother–provider relationships. Mothers have reported that trust was established when providers were compassionate, competent, and consistent [75]. For example, a lack of consistency can undermine a service provider’s ability to be effectively responsive to the needs of mothers experiencing violence. To exemplify, interactions with child protective services are widely variable. A study of 64 women with involvement from child protective services found that some mothers found child protective services helpful—including being counseled to leave their partners and to attend community programs—while other women found it unhelpful as they were told there were no services available to them [76]. The lack of consistency and trust in child protective services is particularly concerning for mothers as there is the constant fear that children will be removed. Many mothers who have experienced violence are faced with the potential or actual removal of children in cases of allegations of domestic violence, thus subjecting women to profound grief and loss described as analogous to experiencing a child’s death [77]. Mothers also reported that child protective services often placed the reasonability solely on the mothers to ensure the child’s safety, even if the abusive fathers had continued access to the child(ren). Research exploring the experience of mothers who are involved with child protection has identified that mothers wanted the workers to be prepared to listen to the mother’s situation, validate her experiences, and attend to the nuance of her situation (e.g., not receiving ‘canned responses’) while providing ongoing support and concrete assistance to ensure that the mother and child(ren)’s situation became and remained safe [77].

Access. Women leaving abusive relationships often need assistance with navigating and accessing resources. Access to resources, particularly financial, can make a significant difference in the ability of women to leave abusive relationships [50]. To improve access to services, funding is needed for community-based programs that provide support and services to women experiencing GBV. There is overwhelming evidence that shelters in Canada are forced to do more with less and are often in a state of financial austerity, which limits their ability to provide services to mothers experiencing violence [78]. There is a need for increased and stable funding for women’s shelters and anti-violence programs across Canada. Further, stronger laws and policies that address GBV can provide greater protection for women and encourage them to come forward and seek help. This can include measures such as mandatory reporting of GBV by healthcare providers, increased penalties for offenders, and better access to justice for survivors [78].

7. Conclusions

Gender-based violence among childbearing women—including antenatal, intrapartum, and postpartum women—is complex and has many interrelated parts. As such, approaching ways to better understand these intersecting phenomena and potential means of addressing challenges calls for an intersectional approach. Despite the complexity of GBV among antenatal, intrapartum, and postpartum women, there are opportunities for action at different levels, including individual, institutional, and structural levels. From an institutional and structural level, it is important to recognize and address the intersecting forms of oppression that individuals may face to promote health equity among women facing violence. Promotion of health equity includes implementing healthcare policies and practices that address systemic inequalities, promote inclusivity and diversity, and ensure that healthcare services are accessible, culturally sensitive, and responsive to the needs of all individuals. Addressing the social consequences of oppression requires collective efforts to dismantle systemic barriers, promote inclusivity, and ensure equal rights and opportunities for all individuals. Furthermore, addressing GBV among childbearing women involves creating spaces for dialogue, challenging stereotypes and biases, promoting social justice, and advocating for policies that promote equality and empower marginalized communities. Addressing the political consequences of oppression requires fostering democratic governance, protecting human rights, promoting inclusivity and political participation, and ensuring the rule of law. In addition, it involves advocating for political reforms, supporting civil society organizations, and fostering international cooperation to challenge oppressive systems and promote political freedom and justice. Oppression has significant political consequences that can shape the functioning of societies and political systems. Marginalized groups that experience oppression often face barriers to political participation. Discriminatory laws, voter suppression tactics, or social exclusion can limit their ability to engage in the political process, resulting in their voices being unheard and their interests not being adequately represented. From an individual and interpersonal level, opportunities exist in the spheres of professional practice, public awareness, and community engagement. For example, holistic, community-based, comprehensive, and accessible support services can more effectively support the specific needs of pregnant and postpartum women facing GBV. Enhanced training programs for health and social service (e.g., nurses and allied healthcare providers, social service workers, and law enforcement professionals) providers with a focus on: (1) identifying signs of GBV; (2) understanding the impact of GBV on maternal and infant health; and (3) increasing skills and knowledge to enable sensitive and timely responses can considerably improve the care/services received by women, with greater potential for enhanced individual wellbeing. Finally, raising public awareness of the issues facing childbearing women in the context of GBV can reduce stigma, decrease violence and its effects, and promote more supportive environments.