Intimate Partner Violence During Pregnancy

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Intimate Partner Violence During Pregnancy

• A Guide for Clinicians

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Facts About Intimate Partner Violence (IPV)

• Affects approximately 1.5 million women each year
• Affects as many as 324,000 pregnant women each
  year
• May be more common than conditions for which
  pregnant women are routinely screened
• Possibly associated with unintended pregnancy,
  delayed prenatal care, smoking, alcohol and drug
  abuse

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All Women Are at Risk

• Victims of IPV come from every
• Age group
• Religion
• Ethnic/racial group
• Socioeconomic level
• Educational background
• Sexual orientation

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Window of Opportunity

• 96 of pregnant women receive prenatal care
• Average of 12?13 prenatal care visits
• Opportunity to developtrust in health care
  provider

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Window of Opportunity

• During pregnancy, victims of IPV may be motivated
  by the
• Desire to be a good parent
• Desire to prevent child abuse
• Opportunity to think about the future

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Intimate Partner

• Current or former
• Spouse
• Partner
• Boyfriend
• Girlfriend

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Violence

• Coercive control exhibited through
• Physical violence
• Sexual violence
• Threats of physical or sexual violence
• Psychologic or emotional abuse

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Physical Violence

• Intentional use of force, such as
• slapping scratching
• pushing choking
• shaking burning
• biting hitting
• using a knife, gun, or other weapon
• Coercing others to commit such acts

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Sexual Violence

• Actual or threatened use of physical force to
  compel a person to engage in a sexual act against
  her/his will
• Attempted or completed sex act with a person
  unable to
• avoid participation
• communicate unwillingness
• understand the nature of the act
• Abusive sexual contact

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Psychologic and Emotional Abuse

• Humiliating, name-calling, using profanity
• Embarrassing victim deliberatelyespecially in
  public
• Controlling victims movement and activities
• Isolating victim from friends or family
• Controlling financial resources
• Withholding information or resources

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Coercive Control and Intimidation

• Acts perceived by recipient as violent or
  threatening
• Recipients fear of attack or retaliation
• Threats alternated with kindness

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Violence and Pregnancy

• At least 48 of women report violence during
  pregnancy.
• As many as 324,000 women who gave birth in 1998
  experienced violence.

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Violence and Pregnancy

• Violence during pregnancy may be more common
  than
• Gestational diabetes
• Neural tube defects
• Preeclampsia

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Possible Demographic and Psychosocial Factors

• Young maternal age/adolescence
• Unintended pregnancy
• Delayed prenatal care
• Smoking
• Alcohol and drug use
• Lack of social supports
• STD/HIV/AIDS

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Possible Effects on Fetus

• Direct effects
• spontaneous abortion
• fetal injury or death from maternal trauma
• Indirect effects
• maternal stress
• maternal smoking
• alcohol or drug use or abuse

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Possible Risks for Children

• Violence may involve other household members.
• Witnessing violence is a risk factor for abusive
  relationships as an adult.
• Child abuse is associated with depression,
  substance abuse, poor school performance, high-
  risk sexual activity.

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Barriers to Screening

• Time constraints
• Discomfort with the topic
• Fear of offending the patient or partner
• Perceived powerlessness to change the problem

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Use Your RADAR

• Routinely screen every patient
• Ask directly, kindly, nonjudgmentally
• Document your findings
• Assess the patients safety
• Review options and provide referrals
• (Massachusetts Medical Society, 1992)

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Routinely Screen Every Patient

• At first prenatal visit
• At least once per trimester
• At postpartum checkup
• At routine ob-gyn visits and preconception visits

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Components of Screening

• Review medical history.
• Observe and record presentations and behaviors of
  patient and partner.
• Ask direct questions and listen actively.
• Document patients response.

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Review Medical History

• Warning signs of IPV may include
• Previous medical visits for injuries
• History of abuse or assault
• Repeated visits
• Chronic pelvic pain, headaches, vaginitis,
  irritable bowel syndrome
• History of depression, substance use, suicide
  attempts, anxiety

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Review Medical History

• Pregnancy-related factors, such as
• Unintended pregnancy
• Unhappiness about being pregnant
• Young maternal age
• Single marital status
• Higher parity
• Late entry into prenatal care/missed appointments
• Substance use or abuse (tobacco, alcohol, or
  drugs)

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Observe Womans Behavior

• Flat affect
• Fright, depression, anxiety
• Post-traumatic stress disorder (PTSD) symptoms
• dissociation
• psychic numbing
• startle responses
• Overcompliance
• Excessive distrust

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Observe Partners Behavior

• Being overly solicitous
• Answering questions for the patient
• Being hostile or demanding
• Never leaving the patients side
• Monitoring the womans responses to questions

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Ask Directly

• Ask questions in private.
• apart from male partner
• apart from family or friends
• Explain issues of confidentiality.
• Be aware of mandatory reporting laws in your
  state and inform the woman of them.

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Ask Directly
Violence is a problem for many women. Because
it affects health and well-being, I ask all my
patients about it.
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Open the Door

• Find your own way of phrasing questions.
• Be prepared to hear your patients answer.
• Face-to-face talk is more effective than written
  patient questionnaires.
• Caring, empathetic questions may open the door
  for later disclosure.

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Abuse Assessment Screen

• Short
• Tested in clinical settings
• Effective in identifying violence

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Abuse Assessment Screen
1. In the last year (since I saw you last), have
you been hit, slapped, kicked, or otherwise
physically hurt by someone? (If yes, by whom?
Number of times? Nature of injury?) 2. Since
youve been pregnant, have you been hit,
slapped, kicked, or otherwise physically hurt by
someone? (If yes, by whom? Number of times?
Nature of injury?)
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Abuse Assessment Screen
3. Within the last year has anyone made you do
something sexual that you didnt want to do? (If
yes, who?) 4. Are you afraid of your partner
or anyone else?
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Additional Questions
Emotional Abuse Does your partner (former
partner) ever humiliate you? Shame you? Put you
down in public? Keep you from seeing friends or
from doing things you want to do? Child
Abuse Within the last year, has someone made
you worry about the safety of your child? (If
yes, who?)
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Questions Not to Ask

• Why dont you just leave?
• What did you do to make him/her so angry?
• Why do you go back?

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Reasons for a No Response

• Embarrassment/shame
• Fear of retaliation by partner
• Lack of trust in others
• Economic dependence
• Desire to keep family together
• Unaware of alternatives
• Lack of support system

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Responding to No

• Always chart the womans responseeven when she
  says no.
• Your questions may help those experiencing abuse
  to move closer to disclosure.
• Your questions indicate your willingness to
  discuss the violence.
• Your questions will let the woman know you and
  other staff are always available as resources.
• Women will choose when to disclose.

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Responding to Yes

• Things you can say
• This is not your fault.
• No one deserves to be treated this way.
• Im sorry youve been hurt.
• Do you want to talk about it?
• I am concerned about your safety (and that of
  your children).
• Help is available to you.

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Document Your Findings

• In the patients chart
• In the patients own words
• With a body map
• With photographs (get consent)
• With specific details

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Assess Patients Safety

• Is either the woman or her children in danger?
• Has violence escalated recently?
• Are there weapons in the home?
• If the patient is not safe, does she have a
  safety plan?

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Components of a Safety Plan

• Pack a bag in advance.
• Have personal documents ready.
• Hide extra sets of house and car keys.
• Establish a code with family or friends.
• Plan where to go.

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Patient Options
1. Stay with abuser and formulate a safety
plan 2. Remove abuser through arrest or
protective orders 3. Leave the relationship
temporarily or permanently
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Referrals

• Keep a current list of local resources
• Office and hospital personnel with special
  training
• Law enforcement (police, lawyers, advocates)
• Shelters (housing, support groups, advocates)
• Local hotlines
• Child protective services

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Referrals
Keep a current list of local resources

• Mental health services
• Trained clergy
• Victim advocates
• Legal services
• Social workers

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National Toll-Free Hotlines
800-799-SAFE800-787-3224(TTD)
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Collaborative Response
Religious Leaders
Advocates

Police
Health Professionals
Employers
Friends
Judges Legal Professionals
Policy Makers
Educators
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For More Information
ACOG(202) 638-5577www.acog.org/goto/noviolence
CDC(770) 488-5259www.cdc.gov/nccdphp/drh/wh_vi
olence.htm