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Intimate Partner Violence: Urgent Implications for Women's Health


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Title: Intimate Partner Violence: Urgent Implications for Women's Health

Intimate Partner Violence Urgent Implications
for Women's Health
  • Nancy Glass, PhD, MPH, RN
  • Co-Director, Center for Health Disparities
  • Oregon Health Science University

  • Define intimate partner violence (IPV).
  • Describe the overlap of forms of IPV.
  • Describe the prevalence of this public health
  • Describe physical, psychosocial and pregnancy
    related effects of IPV.

  • Discuss use of assessment tools in clinical
  • Identify local and national resources for women
    in abusive relationships.

Definition Intimate Partner Violence
  • Centers for Disease Control and Prevention (CDC)
  • Physical and/or sexual violence (use of physical
    force) or threat of such violence or
    psychological/ emotional abuse and/or coercive
    tactics when there has been prior physical and/or
    sexual violence between persons who are spouses
    or non marital partners (dating,
    boyfriend-girfriend, same-sex) or former spouses
    or non marital partners (Saltzman 99)

Definition Intimate Partner Violence
  • Conceptualized as a risk factor for many health
    problems rather than a disease or syndrome or

(No Transcript)
Intimate Partner Violence
  • Population-based telephone survey (N8000 women)
    (Tjaden Thoennes, 1998)
  • 25 of women reported lifetime physical and/or
    sexual assault by an intimate or ex-intimate
  • Estimated 4.8 million women report
    physical/sexual violence from an intimate in the
    past year.
  • 40 of assaults result in injuries
  • 20 seek health care services related to the
  • 10 of Oregon women report physical/sexual
    violence from an intimate in the past year
    (Oregon DHHS).

Overlap between physical, sexual and emotional
abuse (N 889) (Campbell et. al. 02)
Sexual (N 243)
32 (3.6)
14 (1.6)
31 (3.5)
166 (18.7)
177 (19.9)
166 (18.7)
303 (34.0)
Emotional (N 677)
Physical (N 649)
General Health Outcomes
  • Serious health outcomes, last long after the
    violence has ended.
  • Survivors of IPV report poorer overall health
    status, poorer quality of life, and functional
    status as compared to women who report never
    experiencing IPV (Glass 2001, Sullivan et al.,
    1999 Plichta, 1996).

Health Effects - 5 Major Studies (controlled,
pop based or large HMO Campbell et. al. 02
Coker Leserman McCauley Plichta 96)
Health Effects - 5 Major Studies (controlled,
pop based or large HMO Campbell et. al. 02
Coker Leserman McCauley Plichta 96)
Mental Health Outcomes
  • Depression and Post Traumatic Stress Disorder
    (PTSD) most commonly reported mental health
    outcome of IPV (Campbell, 2001 Glass, 2001
    Campbell et al., 1997 Campbell et al., 1995)
  • 59.2 of injured women from a Level 1 Trauma
    Center reported symptoms of PTSD (up to 5 years
    after the injury) (Glass, 2001)
  • Relationship between IPV and suicidiality
    (McCauley et al., 1995)

Mental Health Outcomes
  • Substance Use (ETOH, illegal drugs, prescription
    drugs). (Sharps et al., 2001)
  • Women with depression and/or PTSD may use
    substances to calm, cope with all three PTSD
    specific symptoms clusters (intrusion, avoidance,
    and hyperarousal)
  • Dangerous reciprocal relationship between
    violence re-victimization and substance use
    (Dansky et al., 1997)

Health Care Utilization
  • Examined relationship of IPV and health care
    utilization in population and clinical studies
    has revealed poorer overall physical and mental
    health, higher incidence of injuries, increase
    consumption of health care resources
    (hospitalization, health visits, prescriptions)
    (McCauley et al., 1995 Campbell et al., 2001).
  • Although there is an increased use of health
    care by abused women, only 20 are correctly
    identified (Campbell et al., 2002)

Prevalence Pregnancy-Related Violence
  • IPV during pregnancy range from 0.9 to 20.1
    (Gazmararian et al., 1996)
  • The majority of studies, the prevalence estimate
    has ranged from 4-8
  • Wide range of prevalence estimates likely the
    results of a variety of measures, populations
    sampled and methodology

Oregon Prevalence Pregnancy Related Violence
  • Findings are based on the results of the 2000
    Oregon DHS Pregnancy Risk Assessment Monitoring
    System (PRAMS)
  • Ongoing survey of women who have recently given
  • 2,100 new mothers participated in the
    representative sample

Oregon Prevalence Pregnancy-Related Violence
  • During your recent pregnancy did your husband or
    partner push, hit, slap, kick, choke or
    physically hurt you in any other way"
  • 2.6 of respondents answered YES
  • Additionally, 0.8 of respondents, reported that
    someone else had physically hurt them while they
    were pregnant (ex-partner, ex-boyfriend)
  • 1,472 new mothers reported being physically hurt
    while pregnant in 2000

Oregon Prevalence Pregnancy Related Violence
  • In addition to violence during the pregnancy
  • 3.8 of respondents reported being physically
    hurt by their husband or partner in the 12 months
    before they became pregnant
  • Another, 1.6 of respondents, reporting being
    physically hurt by someone else in the 12 months
    before they became pregnant
  • 2,339 new mothers reporting being physically hurt
    in the year prior to the pregnancy

Pregnancy and Violence
  • Public health perspective, an important question
    is risk patterns to develop prevention programs
    to reduce IPV during pregnancy
  • Are pregnant women at a greater risk of
    physical/sexual violence by their male partners
    or ex-partners compared to women who are not
  • Studies using national probability samples (e.g.
    National Family Violence Survey, 1985 1992
    National Alcohol and Family Violence Survey
    National Survey of Families and Households, 1988)
    have indicated that pregnant women were no more
    likely to be victims of IPV than women who were
    not pregnant
  • In one survey, National Survey of Families and
    Households, 1988, persistent violence was more
    likely to occur among couples in which the male
    partner perceived that the pregnancy of his
    female partner occurred sooner than intended

Risk Factors for Pregnancy-Related Violence
  • Cumulative effect of multiple contextual and
    relationship factors and stressors, can impact
    parental perception of newborns, family
    environment, attitudes toward parenting, and
    levels of relationship discord (Fisher et al.,

Consequences of Pregnancy-Related Violence
  • Consequences for both the unborn child and
    pregnant mother
  • Late entry into prenatal care
  • Low birth weight babies
  • Premature labor
  • Unhealthy maternal behaviors
  • Fetal trauma
  • Health issues for the mother

Consequences of Pregnancy-Related Violence
  • Late entry into prenatal care
  • Healthy People 2010, 90 of pregnant women will
    begin prenatal care in first trimester
  • Abused women are twice as likely to delay
    prenatal care until the 3rd trimester compared to
    women who were not abused (Goodwin et al., 2000)
  • Late entry to prenatal care is a risk factor for
    pregnancy complications including low birth
    weight babies and premature labor

Consequences of Pregnancy-Related Violence
  • Low birth weight and Premature Labor
  • Studies have been inconsistent in findings
    related to the association between IPV, premature
    labor and low birth weight infants (Curry
    Harvey, 1998 Cokkinides et al., 1999).
  • In addition to IPV, low birth weight and
    premature labor may be associated with late entry
    into prenatal care, as well as unhealthy
    behaviors by the mother (e.g. smoking, poor

Consequences of Pregnancy-Related Violence
  • Fetal Trauma (e.g miscarriage, spontaneous
  • Experiencing IPV puts the unborn baby at risk
  • Increased risk of miscarriage (Jacoby et al.,
  • Association between current IPV and at least one
    spontaneous abortion in the womans obstetric
    history (Jacoby et al., 1999)
  • Increased risk of placental abruptions (Connolly
    et al., 1997)

Consequences of Pregnancy-Related Violence
  • Unhealthy Maternal Behaviors
  • IPV indirect contribution to negative
    consequences for both unborn child and mother by
    increasing the risk for unhealthy maternal
  • Abused women are more likely to smoke during
    pregnancy than women who are not abused
    (Cokkinides Coker, 1998)
  • Prenatal patients (n2000), victims of IPV were
    more likely to smoke, drink and use drugs than
    women who were not abused (Martin et al., 1996)
  • IPV victims were more likely to be in the most
    severe substance abuse category during pregnancy
    than nonabused women (Martin et al., 1996)

Consequences of Pregnancy-Related Violence
  • Health Issues for Mothers
  • Unhealthy diet, severe postpartum depression,
    lower self-esteem, breastfeeding difficulties,
    anemia and poor weight gain have all been
    associated with IPV and pregnancy (Bohn Holz,

  • Femicide, murder of women
  • 7th leading cause of premature death for women in
  • 2 cause of death - African-American women aged
  • 40-50 of US femicides by an intimate partner or
    ex-intimate partner (SHR analyses misclassifies
    many Langford, 98)
  • 67-80 of intimate partner femicides were
    previously battered by their murderer

Pregnancy and Femicide
  • Femicide
  • Femicide accounted for 25 of the injury deaths
    of pregnant women in NY City (Dannenberg et al.,
  • 13 of pregnancy related deaths were femicides in
    NC (Parsons Harper, 1999)
  • 11 city study on intimate partner femicide,
    victims of femicide or attempted femicide were
    more likely to have been abused during pregnancy
    by the perpetrator than the comparison group of
    abuse women (McFarlane et al., 1999).
  • Study found a 3 fold increased risk of femicide,
    if the woman was abused during pregnancy

Pregnancy and Femicide
  • Femicide
  • Pregnancy in and of itself is NOT a risk factor
    for femicide
  • Abuse during pregnancy is one of several risk
    factors for femicide/attempted femicide

  • Femicide
  • Important to note other significant risk factors
  • Previous threats to kill her
  • Partner/ex-partner unemployed and not looking for
  • Partner/ex-partner is not the biological parent
    of a child living in the home
  • Woman is leaving the relationship and
    partner/ex-partner is controlling
  • Partner/ex-partner owns a gun

Kerry Repp Act-Oregon
  • Focus on women as victim of violence during
  • Raise awareness of pregnancy as a dangerous time
    for some abused women
  • Training for health care professionals, coroners,
    law enforcement, judges related to lethality and

Kerry Repp Act-Oregon
  • We need to know if femicide is the leading cause
    of maternal mortality in Oregon
  • Multidisciplinary Fatality Review System
  • State and County levels
  • Surveillance system of femicides in Oregon
  • Develop prevention and intervention strategies

Effects of IPV on Children
  • Anxiety reactions and post-traumatic stress
    symptoms, e.g., irritability, agitation, trouble
    concentrating, exaggerated startle response,
    intrusive, unwanted memories
  • School problems, e.g., declining grades,
    behavioral problems, truancy, suspensions,
  • More physical health problem than general
  • Worries about their mothers actual (e.g.,
    battering) and potential (e.g., smoking,
    pregnancy) health hazards
  • Later, higher levels of violent behavior and
    arrests in children who have themselves been
    abused or neglected

Missed Opportunities
  • Few women report being asked about IPV at their
    health care visit (Glass et al., 2001)
  • 41 of women murdered by intimate or ex-intimate
    partner were seen at a health care agency for an
    injury or mental health issue in the year prior
    to murder (Sharps et al., 2001)
  • 20 of perpetrators of partner homicide were seen
    by a physician or mental health provider in year
    prior to murder (Sharps et al., 2001)

Public Health Problem
Health Policy Screening
Screening literature evidence insufficient
  • Ramsey et al., British Medical Journal, 2002
  • MacMillan Wathen, Canadian Task Force on
    Preventive Health Care, JAMA 2003
  • Anglin Sachs., Acad Emerg Med, 2003
  • Nelson et al., US Preventive Service Task Force,
    Annals Int Med., 2004

  • Sometimes clinical judgement trumps Cochrane.
    Sometimes humanity trumps evidence. Or perhaps
    the type of evidence we demand for this kind of
    healing should be different from what we demand
    for the efficacy of anticoagulation in atrial
  • Lachs, Ann Intern Med 2004 p. 400

Who to screen?
  • EVERYONE! (Routine, Universal Screening)
  • Only 56 of women presenting to the ED because of
    intimate partner violence had an injury related

How to Screen for IPV
  • Display visual information
  • How far does someone have to go in your setting
    before they know it is OK to talk about IPV?
  • Ask in private
  • Strategies to remove others from room prior to
  • Make it a safe process
  • Be nonjudgemental

What to ask?
  • Keep it simple!
  • How you ask more important than what you ask!
  • Have you been injured by a partner or ex-partner
    in the past year?
  • Is there anyone making you feel unsafe?
  • Has anyone made you have sex against your will?

Abuse Assessment Screen
1. Have you ever been emotionally or physically
abused by your partner or someone important to
you? 2. Within the last year, have you been hit,
slapped, kicked, pushed or shoved, or otherwise
physically hurt by your partner or ex-partner?
If YES, by whom Number of times 3. Does
your partner ever force you into sex? 4. Are you
afraid of your partner or ex-partner? Heltin
McFarlane, 1986 Mark the area of any injury on
body map.
Does Screening Identify Women at Risk?
  • Women with a positive partner violence screen are
    9 times more likely (28 vs. 2) to experience
    physical violence in the next three months
    (Koziol-McLain, 1999).

  • Use her words
  • Name of perpetrator
  • History of abuse
  • Body Map, Photographs
  • Danger Assessment (Lethality, Suicide,
  • Interventions (Safety Plan)
  • Referrals (Hotline, Shelter, Legal, Police)

Assess Safety
  • Escalating violence (lethality)
  • Use or threat of weapon (gun, knife)
  • Lack of support and isolation
  • Recent separation from partner
  • Risk to children
  • Depression
  • Risk for suicide

Danger Assessment (Campbell, 2004)
  • Developed in 1985 to increase battered womens
    ability to take care of themselves (Self Care
    Agency Orem 81, 92)
  • Interactive, uses calendar - aids recall plus
    women come to own conclusions - more persuasive
    in adult learner/ strong woman/ survivor model
  • Intended as lethality risk instrument versus
    reassault (e.g. SARA, K-SID) - risk factors may
    overlap but not exactly the same

Danger Assessment
  • 20 items yes/no plus calendar
  • Shows pattern - frequency severity of past year
  • Aids recall
  • Summative, no cutoff
  • 10 samples of 2251 battered women
  • Internal consistency .60-.86 test-retest
  • Construct validity convergent w/CTS ISA (r
    .55-.75) discriminant group

(7233)Family Violence Prevention