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Intimate Partner Violence During Pregnancy A Guide for Clinicians.

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Presentation on theme: "Intimate Partner Violence During Pregnancy A Guide for Clinicians."— Presentation transcript:

1 Intimate Partner Violence During Pregnancy A Guide for Clinicians

2 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 Facts About Intimate Partner Violence (IPV)

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

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

5 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 Window of Opportunity

6 Current or former: Spouse Partner Boyfriend Girlfriend Intimate Partner

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

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 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 Sexual Violence

10 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 Psychologic and Emotional Abuse

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

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

14 Young maternal age/adolescence Unintended pregnancy Delayed prenatal care Smoking Alcohol and drug use Lack of social supports STD/HIV/AIDS Possible Demographic and Psychosocial Factors

15 Direct effects -spontaneous abortion -fetal injury or death from maternal trauma Indirect effects -maternal stress -maternal smoking -alcohol or drug use or abuse Possible Effects on Fetus

16 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. Possible Risks for Children

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

18 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) Use Your “RADAR”

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 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. Ask Directly

26 “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 Mental health services Trained clergy Victim advocates Legal services Social workers Keep a current list of local resources:

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

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

44 For More Information ACOG (202) 638-5577 CDC (770) 488-5259 wh_violence.htm

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