All women and men of reproductive age will achieve optimal health and wellness, fostering a healthy life course for them and any children they may have.Background
- Intimate partner violence (IPV) is defined by the CDC as “physical, sexual, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy.” (http://www.cdc.gov/violenceprevention/intimatepartnerviolence/definitions.html )
- IPV can take many forms:
- Physical abuse
- Sexual assault
- Isolation
- Intimidation
- Stalking
- Reproductive coercion, (behaviors that interfere with contraceptive use and pregnancy), including:
- Pressuring a partner to have sex
- Interfering with effective contraceptive use
- Forcing sex without a condom
- Intentional exposure of partner to STI’s
- Pressuring partner to conceive
- Pressuring partner to continue or terminate a pregnancy
- While intimate partner violence can be perpetrated on anyone, it is most prevalent in women of reproductive age.
- IPV is present in all population groups, irrespective of age, socio-economic status, education, race, ethnicity and religion.
- Women in the military and veterans are at increased risk for IPV (ACOG, 2012b).
- More than one-third of women in this country have experienced physical violence, stalking by an intimate partner and/or rape;
- The true prevalence of IPV is unknown because of under-reporting.
- IPV was identified as the cause of death for 2,340 people in 2007: 1,640 were female (ACOG, 2012a)
- Homicide is a leading cause of maternal mortality in the U.S. with the majority caused by current or former intimate partners (ACOG, 2012a)
- Beyond mortality, IPV is associated with:
- Physical disabilities
- Chronic health conditions
- Post-traumatic stress disorder
- Substance abuse
- Unintended pregnancy
- Fetal injury
- Prematurity and low birth weight
- IPV may result in unintended or unwanted pregnancies.
- One survey found that 25% of women calling the National Hotline on Domestic Violence had been forced or pressured by a partner to become pregnant (Chamberlain and Levenson, 2009).
- Approximately 325,000 pregnant women are the victims of intentional injury each year (again, estimates are likely low) (ACOG, 2012 a).
- Violence may begin or escalate during pregnancy and the postpartum period.
- Screening for ongoing and historical IPV should be incorporated into the primary care of all women (ACOG, 2012 a).
- Clinical practices can encourage disclosure by displaying posters and educational brochures in the office and making access to take-home resources such as safety procedures, hotline numbers and referral numbers available in private spaces such as examining rooms and restrooms. (Chamberlain and Levenson, 2012; ACOG, 2012a)
- Women are unlikely to volunteer IPV but may reveal it during a clinical encounter.
- Routine repeated screening may encourage women, over time, to reveal their circumstances.
- Screening for non-pregnant women should occur at:
- Routine visits (“every woman, every time”)
- Family planning visits
- Dedicated preconception visits
- Screening can be included in self-administered questionnaires but a face-to-face assessment is essential; this assessment needs to done in a private setting without the presence of parents, partners or friends.
- If an interpreter is necessary, use professional language interpreters rather than someone known to the woman.
- Clinicians and offices need to be aware of the laws in their specific state relative to IPV as some states may have mandatory reporting.
- For more information on reporting laws in your state go to: http://www.acf.hhs.gov/fvpsa or http://www.futureswithoutviolence.org/userfiles/file/HealthCare/Compendium%20Final.pdf.
- ACOG (2012 a) recommends that all women be screened for IPV by asking simple questions prefaced by an introductory statement such as:
- “Because violence is so common in many women’s lives and because there is help available for women being abused, I now ask every patient about domestic violence”
- Screening should involve face-to-face interactions with the patient and should use a series of direct questions such as (Chamberlain and Levenson, 2012):
- Are you in a relationship with a person who threatens or physically hurts you?
- Within the past year have you been hit, slapped, kicked or otherwise physically hurt by someone?
- Do you ever feel afraid of your partner?
- Has anyone forced you to have sexual activities that made you feel uncomfortable?”
- Does your partner support your decision about when or if you want to become pregnant? This query, suggested by ACOG (2013) has particular preconception/family planning significance.
- All women experiencing current or recent IPV need a plan for safety and referral to support services (Chamberlain and Levenson, 2012).
- Educate your staff about this important component of care and the need to work as a team to assure that disclosure feels safe for the women served by your practice. An excellent resource to educate you, your partners, and your staff about tested strategies to address IPV is available at Futures without Violence: http://www.futureswithoutviolence.org/
- Research cited by Futures without Violence has shown that:
-
- A brief intervention that uses a safety card and includes referral to a local domestic violence or advocacy support agency is simple and effective. (Chamberlain and Levenson, 2012);
- To help clinicians address IPV, a local domestic violence agency is an important asset.
- Providers can help patients connect with an advocate to work on a safety plan and additional services such as housing, legal advocacy and support groups/counseling. This can be done with this simple phrase such as:
-
- “If you are comfortable with this idea, I would like to call my colleague at the local program (fill in person’s name) who is really an expert in what to do next and she can talk with you about supports for you and your children from her program”.
- If you do not already have a relationship with a local agency or advocate, provide a ‘warm’ referral to the National Domestic Violence Hotline (800.799.SAFE), the National Sexual Assault Hotline (800.656.HOPE), or the National Dating Violence Hotline (866.331.9474). This might be done by saying:
-
- “There are national confidential hotline numbers and the people who work there really care and have helped thousands of women. They are there 24/7 and can help you find local resources and often can connect you by phone” (adapted from: http://www.futureswithoutviolence.org/
- The Affordable Care Act (ACA) includes “screening and counseling for all women and adolescent girls for interpersonal and domestic violence in a culturally sensitive and supportive manner” as one of the covered services. http://www.futureswithoutviolence.org/userfiles/file/HealthCare/FWV-screening_memo_Final.pdf).
- Intimate partner violence and reproductive coercion can happen in any segment of the population.
- Explain to every woman that you include this area of health inquiry for every woman at least annually as part of a routine health assessment.
- Tell the woman that responses are confidential (if you are in a state with mandatory reporting requirements, learn about what must be reported and explain the law to the woman as well as safeguards for her privacy and safety).
- Pregnancy does not provide a safe haven for women who are in relationships marked by disrespect, coercion, and violence and IPV may, in fact, increase during pregnancy.
- Women are unlikely to leave relationships marked by IPV until they know of safe and supportive alternatives.
- There are resources that can help a woman her options.
- Making the changes necessary to overcome IPV are likely to take time. Convey to the woman that you and your staff are committed to her safety, available to support her decisions as she deals with a difficult situation and available to help her take steps to achieve a safer and more respectful future.
Clinical Guidance
- Explain that you regularly ask all women a series of questions to assess their safety.
- Explain that her answers will be held in confidence.
- If your state has a mandatory reporting policy that may apply to the conversation, this needs to be disclosed prior to collecting information on IPV (see Background)
- Suggested queries include:
- Are you in a relationship with a person who threatens or physically hurts you?
- Within the past year have you been hit, slapped, kicked or otherwise physically hurt by someone?
- Do you ever feel afraid of your partner?
- Has anyone forced you to have sexual activities that made you feel uncomfortable?”
- A related query that specifically addresses pregnancy intention and the potential for sexual coercion is:
- Does your partner want you to become pregnant in the next year?
- If the woman answers “yes” to any of the first 4 screening questions, acknowledge the trauma and your concern for her welfare, provide referrals to local and national resources and encourage woman to develop a safety plan.
- Consider designating a staff member to assume the role of educating women about safety plans and helping them make contacts with appropriate support services.
- If the woman wants to act immediately offer your clinic’s phone for her to make the necessary connections (women in abusive relationships often have their cell phones monitored by their abuser).
- If the woman discloses a lack of concordance between her desires and her partners desires for pregnancy in the next year, discuss strategies to help her define and achieve her personal goals (such as providing a highly effective method that is unlikely to be discovered and undermined by her partner).
- Acknowledge that making a change is likely to take time and that you and your staff are available to help her take steps to achieve a safer and more respectful future.
Clinical Tools
Addressing Intimate Partner Violence, Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic and Reproductive Health Care Settings (2012).
http://www.futureswithoutviolence.org/userfiles/file/HealthCare/reproguidelines_low_res_FINAL.pdf
Futures without Violence: Provider/Patient Tools. A very rich resource with many tools and resources for your practice (2013).
http://futureswithoutviolence.org.
Futures without Violence. Making the Connection: Intimate Partner Violence and Public Health (Powerpoint presentation) (2010).
http://www.futureswithoutviolence.org/section/our_work/health/_making_connection .
Futures without Violence: Compendium of State Statutes and Policies on Domestic (2010).
http://www.futureswithoutviolence.org/userfiles/file/HealthCare/Compendium%20Final.pdf.
Canadian Women’s Health Network: Getting Through Medical Examinations : A Resource for Women Survivors of Abuse and Their Health Care Providers ( 2000). This site provides information especially relevant to the care of women who have suffered sexual abuse at some time in their lives.
http://www.cwhn.ca/en/print/yourhealth/faqs/GettingThroughMedicalExaminations
National Domestic Violence Hotline (2013). This site provides women access to a telephone service that offers 24 hour counseling and interventions. http://www.thehotline.org/
National Online Resource Center on Violence against Women (2013).
http://www.vawnet.org/
NY Health Department: IPV: Encouraging Disclosure and Referral in the Primary Care Setting (2007).
http://www.nyc.gov/html/doh/downloads/pdf/chi/chi26-2.pdf
Guide for Working with Patients with a Previous History of Sexual Abuse (2009).
http://www.csacliniciansguide.net/
CDC: IPV during Pregnancy, A Guide for Clinicians (2012).
http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/index.htm
Screening Tool: Women’s Experiences of Battering (WEB) Scale (2012).
http://www.dbhds.virginia.gov/library/document-library/scrn-pw-web.pdf
Project Courage R3 iPhone app for patients and health professionals (screening and resource tool)
Patient Resources
Futures without Violence: Provider/Patient Tools. A very rich site with many resources for any woman in an unsafe environment (2013).
http://futureswithoutviolence.org
Reproductive Health Safety Cards.
http://www.futureswithoutviolence.org/?s=reproductive+health+safety+cards
Canadian Women’s Health Network: Getting Through Medical Examinations : A Resource for Women Survivors of Abuse and Their Health Care Providers (2000). This site provides information especially relevant to women who have suffered sexual abuse at some time in their lives. http://www.cwhn.ca/en/print/yourhealth/faqs/GettingThroughMedicalExaminations
National Domestic Violence Hotline (2013). This site provides women access to a telephone service that offers 24 hour counseling and interventions. http://www.thehotline.org/
Project Courage R3 iPhone app for patients and health professionals (screening and resource tool)
References
American College of Obstetricians and Gynecologists. (2012a). Intimate partner violence. Committee Opinion #518. Obstetrics & Gynecology. 119 (2 Pt1), 412-417.
American College of Obstetricians and Gynecologists. (2012b). Health care for women in the military and women veterans. Committee Opinion #547. Obstetrics & Gynecology. 120(6) 1538-1542.
American College of Obstetricians and Gynecologists (2013), Reproductive and sexual coercion. Committee Opinion #554. Obstetrics & Gynecology. 121 (2 Pt 1), 411-415.
American College of Obstetricians and Gynecologists, District IX/CA. Postpartum Visit Algorithm: Domestic Violence Screening. Retrieved January 21, 2013 from:
http://www.everywomancalifornia.org/content_display.cfm?contentID=359&categoriesID=120&CFID=1473275&CFTOKEN=70414513.
Chamberlain, L. & Levenson, R. (2012). Addressing Intimate Partner Violence, Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic and Reproductive Health Care Settings ( 2nd ed).. Futures Without Violence: San Francisco (CA). Retrieved January 21, 2013 from: http://www.futureswithoutviolence.org/userfiles/file/HealthCare/reproguidelines_low_res_FINAL.pdf .
Futures Without Violence. (2010).The health care costs of domestic and sexual violence. Retrieved January 21, 2013 from:
http://www.futureswithoutviolence.org/userfiles/file/HealthCare/Health_Care_Costs_of_Domestic_and_Sexual_Violence.pdf
Institute of Medicine. (2011). Recommendations. In: Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: National Academies Press. Retrieved January 21, 2013 from:
http://www.iom.edu/Reports/2011/Clinical-Preventive-Services-for-Women-Closing-the-Gaps.aspx
Klerman L.V., Jack, B.W., Coonrod, D.V. et. al. (2008). The clinical content of preconception care: care of psychosocial stressors. American Journal of Obstetrics & Gynecology, (6B):S362-6.
Silverman, J.G., Decker, M.R., Reed, E, & Raj, A. (2006). Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S.states: associations with maternal and neonatal health. American Journal of Obstetrics and Gynecology, 195(1): 140-148.
United States Preventive Services Task Force (2013). Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults. Retrieved Feb 4, 2013 from: http://www.uspreventiveservicestaskforce.org/uspstf/uspsipv.htm.
