Intimate Partner Violence During Pregnancy

1. Intimate Partner Violence During Pregnancy A Guide for Clinicians

2. 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

3. All Women Are at Risk Victims of IPV come from every: • Age group • Religion • Ethnic/racial group • Socioeconomic level • Educational background • Sexual orientation

4. Window of Opportunity • 96% of pregnant women receive prenatal care • Average of 1213 prenatal care visits • Opportunity to developtrust in health care provider

5. 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

6. Intimate Partner Current or former: • Spouse • Partner • Boyfriend • Girlfriend

7. Violence Coercive control exhibited through: • Physical violence • Sexual violence • Threats of physical or sexual violence • Psychologicor emotional abuse

8. 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

9. 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

10. Psychologic and Emotional Abuse • Humiliating, name-calling, using profanity • Embarrassing victim deliberately—especially in public • Controlling victim’s movement and activities • Isolating victim from friends or family • Controlling financial resources • Withholding information or resources

11. Coercive Control and Intimidation • Acts perceived by recipient as violent or threatening • Recipient’s fear of attack or retaliation • Threats alternated with kindness

12. Violence and Pregnancy • At least 4–8% of women report violence during pregnancy. • As many as 324,000 women who gave birth in 1998 experienced violence.

13. Violence and Pregnancy Violence during pregnancy may be more common than: • Gestational diabetes • Neural tube defects • Preeclampsia

14. 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

15. 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

16. 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.

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

18. Use Your “RADAR” • Routinely screen every patient • Ask directly, kindly, nonjudgmentally • Document your findings • Assess the patient’s safety • Review options and provide referrals (Massachusetts Medical Society, 1992)

19. Routinely Screen Every Patient • At first prenatal visit • At least once per trimester • At postpartum checkup • At routine ob-gyn visits and preconception visits

20. Components of Screening • Review medical history. • Observe and record presentations and behaviors of patient and partner. • Ask direct questions and listen actively. • Document patient’s response.

21. 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

22. 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)

23. Observe Woman’s Behavior • Flat affect • Fright, depression, anxiety • Post-traumatic stress disorder (PTSD) symptoms: • dissociation • psychic numbing • startle responses • Overcompliance • Excessive distrust

24. Observe Partner’s Behavior • Being overly solicitous • Answering questions for the patient • Being hostile or demanding • Never leaving the patient’s side • Monitoring the woman’s responses to questions

25. 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.

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

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

28. Abuse Assessment Screen • Short • Tested in clinical settings • Effective in identifying violence

29. 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 you’ve been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone? (If yes, by whom? Number of times? Nature of injury?)

30. Abuse Assessment Screen 3. Within the last year has anyone made you do something sexual that you didn’t want to do? (If yes, who?) 4. Are you afraid of your partner or anyone else?

31. 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?)”

32. Questions Not to Ask • Why don’t you just leave? • What did you do to make him/her so angry? • Why do you go back?

33. 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

34. Responding to “No” • Always chart the woman’s response—even 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.

35. Responding to “Yes” Things you can say: • This is not your fault. • No one deserves to be treated this way. • I’m sorry you’ve 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.

36. Document Your Findings • In the patient’s chart • In the patient’s own words • With a body map • With photographs (get consent) • With specific details

37. Assess Patient’s 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?

38. 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.

39. 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

40. 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

41. Referrals Keep a current list of local resources: • Mental health services • Trained clergy • Victim advocates • Legal services • Social workers

42. National Toll-Free Hotlines 800-799-SAFE&800-787-3224(TTD)

43. Collaborative Response Religious Leaders Advocates Police Health Professionals Employers Friends Judges & Legal Professionals Policy Makers Educators

44. For More Information ACOG(202) 638-5577www.acog.org/goto/noviolenceCDC(770) 488-5259www.cdc.gov/nccdphp/drh/wh_violence.htm