Disclosure of intimate partner violence during a shared antenatal visit
Noor is 26, G2P1, at 26 weeks, attending a routine antenatal visit with her husband. He answers most questions for her, sits between her and the door, and refuses to leave during the examination. You notice bruises of different ages on both upper arms and a fresh abrasion on her forearm. She avoids eye contact and gives one-word answers. When her husband steps outside to take a telephone call, she whispers that he has been 'rough' since she lost her job, that he controls all the money, and that she has a three-year-old daughter at home. She begs you not to tell him anything. The clinic has a social worker who attends on Tuesdays, a private room, and a written policy requiring injuries to be documented; national reporting duties for domestic violence must be checked against current regulation and institutional policy.
1. How do you respond in the few minutes available, and what safety information do you need to gather without putting her at greater risk?
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Responding: use the private moment, sit at her level, and keep your voice low and calm. Start with an open statement rather than an accusation: 'You seem worried today - is everything alright at home?' Acknowledge what she has said without judgment: 'Thank you for telling me. That sounds frightening, and it is not your fault.' Do not pressure her to disclose more than she chooses, do not promise secrecy you cannot guarantee, and do not summon the husband or confront him. Avoid writing anything that he could see during the visit.
Safety information to gather gently:
- Whether she feels safe going home today.
- Whether violence has escalated in frequency or severity, and whether there has been strangulation, use of weapons or threats to kill - these are high-risk markers.
- Whether her three-year-old has been hurt or is witnessing the violence.
- Whether she has somewhere to go and someone she trusts, and whether she has money or documents she could access.
- Her own plan: a code word, a bag with documents and medicines, a neighbour or relative she could call.
Give her the clinic's contact number, the relevant national helpline if available, and a safe way to return alone - for example, an appointment for a scan or blood test that gives her a legitimate reason to attend without her husband. Arrange for the social worker to be involved with her consent, and offer a follow-up visit at a time she can attend alone.
2. What are the limits of confidentiality here, and how should the injuries be documented given that her husband may see the notes?
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Limits of confidentiality: confidentiality is the default and she has a right to control who knows. It can be overridden only where there is a clear legal duty or an imminent risk of serious harm - for example a threat to her life or the safety of the child. Even then, the disclosure should be limited to the minimum necessary and, where safe, discussed with her first. Her husband has no right of access to her medical record; a request from him for information should be declined politely and the refusal documented. If the record is shared with a partner in some local practice, that is a serious breach and should be raised with the unit manager.
Documentation: record what she said in her own words, in quotation marks, and describe each injury objectively - size, colour, position, tenderness - on a body map. Photographs require her explicit consent, must be stored securely, and must never be taken on a personal phone. Record the safety assessment, the information given, the referrals made and any refusal of referral, because a refusal is still a decision that must be respected and documented. If the institution's policy permits, use a safe-record approach so that a partner who sees the notes is not endangered: some services keep sensitive details in a sealed section or a separate secure file, with a neutral entry in the main record. Confirm exactly what current Jordanian regulation and institutional policy require regarding reporting, and if you are unsure, escalate to your supervisor rather than making an independent disclosure.
3. Which ethical principles are in tension, and what follow-up plan will you put in place before she leaves the clinic today?
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Principles in tension: respect for her autonomy and her right to make decisions about disclosure competes with the duty to protect her and her child from harm (non-maleficence and beneficence), and with any statutory reporting duty. Telling the husband would violate confidentiality and could escalate the danger, so 'protecting' her by disclosure is not automatically the beneficent act - the most protective thing is usually to strengthen her own safety and choices. There is also a justice dimension: she has no income and depends on her husband, which constrains her options, so practical support matters as much as advice. Her daughter's exposure to violence raises a separate child-safeguarding duty, which may require referral to child protection services under national rules; that should be explained to her honestly and, where possible, done with her knowledge.
Plan before she leaves:
- Confirm she is safe to go home today; if she is in immediate danger, follow the emergency pathway rather than letting her leave without a plan.
- Agree a safe contact method and a follow-up appointment she can attend alone, with a plausible clinical reason.
- Refer to the social worker with her consent and give written helpline and shelter information in a discreet form, not on a piece of paper that could be found.
- Discuss a practical safety plan: important documents, medicines, money, a code word, a neighbour she can call, and what to do if violence escalates.
- Document the discussion, what she agreed to and what she declined, and inform the named safeguarding lead according to policy.
- Arrange a debrief for yourself and confirm the clinic's referral pathway is written down, so the next woman does not depend on one midwife's memory.