Preventing abuse during pregnancy: a clinical protocol

Routine screening for abuse with appropriate intervention during pregnancy is essential to interrupt the cycle of violence and prevent future trauma. Over a decade ago, the Surgeon General called for routine abuse assessment of pregnant women (10). If women are not assessed for abuse, violence will remain undetected and untreated, placing women at risk for escalating abuse and further trauma. Additionally, if follow-up interventions are not implemented once abuse has been confirmed, the cycle of violence will continue. Routine assessment and expanded intervention strategies that includes case management and multi-agency collaboration must become standard care for all pregnant women.

Preventing abuse to pregnant women: implementation of a "mentor mother" advocacy model

Abuse to pregnant women is common and can result in complications to maternal and child health. Although screening and detection of abuse in primary health care settings is becoming more commonplace, intervention models that include community outreach have not been developed or tested. An advocacy model was developed and tested for pregnant abused women by melding research on advocacy programs for abused women exiting shelters with the principles of home visitation used to improve outcomes to pregnant women. Advocacy was offered by "mentor mothers," who were residents of the project's service area. The advocacy consisted of weekly social support, education, and assisted referrals to pregnant women identified as abused as part of routine screening offered at the first prenatal visit to a public health clinic. Effectiveness of the advocacy intervention was measured as contact success rate, number and type of advocacy contacts, and number and type of referrals made to the first 100 women to complete the advocacy program. The mentor mother advocates were successful in contacting the abused woman 33% of the time, regardless of whether a telephone call, home visitation, or in-person meeting was attempted. The average number of advocacy contacts was 9.2 (SD = 7.6) with the majority (74%) being via the telephone. The average number of referrals per woman was 8.6 (SD = 7.6) with the largest percentage (38%) being for medical services. Outreach advocacy as an intervention model for pregnant abused women is recommended.

Symptoms of post-traumatic stress disorder in abused women in a primary care setting

Abuse is a major source of trauma to women, and post-traumatic stress disorder (PTSD) results from exposure to extreme trauma. To describe the relationship between symptoms of PTSD and severity of abuse, an ethnically stratified cohort of 131 abused women in a primary care setting was interviewed. Symptoms of PTSD, both intrusion (i.e., trouble falling asleep, strong waves of feelings about the abuse) and avoidance (i.e., trying not to think or talk about the abuse, staying away from reminders of the abuse), were significantly (p < 0.01) correlated to severity of abuse, regardless of ethnicity. When asked about childhood physical or sexual abuse, women reporting physical abuse had significantly (p < 0.05) higher intrusion scores, whereas those reporting sexual abuse had significantly (p < 0.004) higher avoidance scores. Sixty-five percent of the women reported dreams, flashbacks, or terror attacks and had significantly (p < 0.001) higher mean results on both intrusion and avoidance. The need to offer abused women information about the connection between severity of abuse and symptoms of PTSD is discussed. We recommend that clinicians ask all abused women about dreams, flashbacks, or terror attacks to assess for further symptoms of PTSD.

Resource use by abused women following an intervention program: associated severity of abuse and reports of abuse ending

Although violence against women is recognized as major public health problem, little is known about the effectiveness of interventions. To evaluate severity of abuse and use of community resources following an intervention program, 132 pregnant abused women received three counseling sessions in a prenatal setting. A comparison group of 67 abused women were offered a wallet-sized card listing community resources for violence. Resource use, severity of abuse, and reports of the abuse ending were measured for both groups at 6 and 12 months after delivery. Resource use was significantly (p < .001) related to severity of abuse, irrespective of whether the woman had received the intervention. Women using resources at 6 months were also users at 12 months. These findings indicate a "survivorship model" whereby abused women assertively and persistently seek a variety of community resources to end the abuse. The recommendation that primary care providers go beyond traditional identification and referral for abuse to coordination and evaluation of service delivery is discussed.

Vaginal bleeding and abuse: assessing pregnant women in the emergency department

PURPOSE

This study was done to determine the prevalence of physical abuse among an ethnically stratified group of pregnant women experiencing vaginal bleeding.

DESIGN

The design of this study was a cross-sectional survey using two screening tools: the Abuse Assessment Screen (AAS) and the Danger Assessment (DA).

SAMPLE

The study sample consisted of 261 African-American, Hispanic, and Anglo pregnant women seen for vaginal bleeding in private and public emergency departments in a large (more than 2,000,000 people) metropolitan area.

METHOD

All women with vaginal bleeding were interviewed in a private examination room. With the help of an interviewer, each subject completed both screening tools and was later offered information about abuse as well as community resources. Each woman's pregnancy status was validated with either a urine pregnancy test or a serum beta human chorionic gonadotropin, and her discharge diagnosis was obtained from the emergency department record.

DATA ANALYSIS

Of the 261 pregnant women interviewed, 87 (33.3 percent) reported abuse, that is, 26.7 percent of the African-American women, 25.2 percent of the Hispanic women, and 58.3 percent of the Anglo women. Overall, Anglo women reported significantly more abuse (X2 = 21.96; df = 2; p < .00002) than non-Anglo women. We found no significant differences in reported abuse among the diagnostic groups. Abused and nonabused women significantly (p < .0005) differed on their DA scores (2.89 vs .55, respectively), but these scores were not significantly different among ethnicities.

CONCLUSIONS

Abuse of pregnant women reporting to emergency departments is common and can be detected readily with a two-question, five-minute screen. Once an abused woman is identified, a danger assessment screen can further identify whether she is at high risk for escalating violence in her home.

Physical abuse, smoking, and substance use during pregnancy: prevalence, interrelationships, and effects on birth weight

OBJECTIVE

To establish the singular and combined occurrence of physical abuse, smoking, and substance use (i.e., alcohol and illicit drugs) during pregnancy and its effect on birth weight.

DESIGN

Prospective cohort analysis.

SETTING

Urban public prenatal clinics.

PARTICIPANTS

414 African American, 412 Hispanic, and 377 white pregnant women.

MAIN OUTCOME MEASURE(S)

Occurrence of physical abuse was 16%; smoking, 29.5%; and alcohol/illicit drug use, 11.9%. Significant relationships existed between physical abuse and smoking for African American and white women. For African American women, 33.7% of women who were not abused smoked, versus 49.5% of women who were abused (chi 2 = 8.21; df = 1; p < 0.005). Alcohol/illicit drug use was 20.8% for nonabused women compared with 42.1% for abused women (chi 2 = 18.18; df = 1; p < 0.001). For white women, 46.6% of women who were not abused smoked, versus 59.6% of those who were abused (chi 2 = 5.22; df = 1; p < 0.005). As a triad, physical abuse, smoking, and alcohol/ illicit drug use were significantly related to birth weight (F[3, 1040] = 30.19, p < 0.001).

CONCLUSIONS

Physical abuse during pregnancy is common, readily detected with a five-question screen, and associated with significantly higher use of tobacco, alcohol, and illicit drugs. Clinical protocols that integrate assessment and intervention for physical abuse, smoking, and substance use are essential for preventing further abuse and improving smoking and substance cessation rates.

Abuse during pregnancy: associations with maternal health and infant birth weight

A stratified, prospective cohort analysis was completed on 1,203 African American, Hispanic, and white women. All women were assessed for abuse at the first prenatal visit and twice more during pregnancy. They were also assessed for risk factors of low birth weight using Institute of Medicine correlates. Prevalence of physical or sexual abuse during pregnancy was 16% (1 of 6). Abused women were twice as likely to begin prenatal care during the third trimester, with abuse preceding late entry. Abuse was recurrent, with 60% of the women reporting repeated episodes. More severe abuse was significantly correlated with lower infant birth weights for all three ethnic groups. Abuse during pregnancy was a significant risk for low birth weight as well as maternal low weight gain, infections, anemia, smoking, and use of alcohol and drugs. When compared to women who were not abused, women abused during pregnancy delivered infants averaging 133 g less. Abused white women delivered infants with the greatest reduction in birth weight.

Abuse during pregnancy: frequency, severity, perpetrator, and risk factors of homicide

To determine the frequency, severity, and perpetrator of abuse during pregnancy as well as the occurrence of risk factors of homicide, a stratified, prospective cohort analysis was completed on 1,203 African-American, Hispanic, and Anglo women in urban public health prenatal clinics. All women were assessed for abuse at the first prenatal visit and twice again during the pregnancy. All women were administered the Conflicts Tactics Scale, the Index of Spouse Abuse and the Danger Assessment Scale. Prevalence of physical abuse during pregnancy was 16%, one in every six women. Women abused during pregnancy had significantly higher scores on all instruments and more risk factors of homicide when compared with women abused prior to but not during pregnancy. To protect women's safety, a protocol of assessment and intervention for abuse must be standard care for all pregnant women.

Identification of abuse in emergency departments: effectiveness of a two-question screening tool

OBJECTIVE

A national health objective for the year 2000 is that at least 90% of hospital emergency departments have protocols for routine identification, treatment, and referral for victims of spouse abuse. An effective assessment tool is needed to implement such protocols.

METHODS

To test the effectiveness of a two-question, nurse-administered, screening tool to detect physical abuse, 416 black, Hispanic, and white women coming to public and private emergency departments with vaginal bleeding were asked two questions. Additionally, a 14-item Danger Assessment Scale to determine risk factors of homicide was administered to all women.

RESULTS

In response to the two-question abuse assessment screen, 38% of the 416 women reported a history of physical or sexual abuse. For 61% of the women, the last episode of abuse occurred within the last 12 months. White women reported significantly more abuse than other ethnic groups (chi 2 = 18.71; df = 2; p = 0.00009). Teenagers reported more risk factors of homicide.

DISCUSSION

Abuse to women who seek care in emergency departments is common and easily detected with a straightforward two-question screen. Universal assessment and accompanying information on safety and community resources is essential to interrupt abuse, prevent further trauma and potential homicide, and promote the health and safety of women.

Pregnancies after microsurgical correction of partial epididymal and vasal obstruction

A group of 16 infertile patients suspected of having a partial epididymal obstruction on the basis of severe oligozoospermia, normal-sized testes and a normal serum follicle-stimulating hormone, underwent scrotal exploration. Evidence of partial obstruction of the epididymis was found in 13 cases and of the vas deferens in one case, and was supported by finding normal spermatogenesis on testicular biopsy. Vasoepididymostomy or vasovasostomy were performed, resulting in a significant improvement of semen analysis in 50% of cases and in six pregnancies in two patients. The diagnosis of partial epididymal obstruction should be considered when the above criteria are met. If pregnancies do not result when intracytoplasmic sperm injection (ICSI) is used with the ejaculated spermatozoa, a testicular biopsy followed by a microsurgical by-pass procedure should be considered whenever normal spermatogenesis is diagnosed. In all cases, the epididymal spermatozoa should be aspirated during the operation and either used immediately for insemination or stored frozen. The remarkable results of the new artificial reproduction technologies and in particular ICSI, question the indication for microsurgical correction in cases of partial epididymal obstruction.

The surface exclusion system of RP1: investigation of the roles of trbJ and trbK in the surface exclusion, transfer, and slow-growth phenotypes

The contiguous trbJ and trbK genes of RP1 were cloned individually to study their effects. Surface exclusion was conferred only by trbK and only when gene dosage was high or when trbJ was also present in cis or in trans. This suggests that in the low-copy-number RP1, surface exclusion is due to a two-gene interaction in which trbK is the dominant partner. Among surface exclusion genes, trbJ is novel in yielding a periplasmic product that is also essential for conjugal transfer. This cellular location and the disturbed membrane function that accompanies TrbJ-processing probably accounts for the retarded growth caused by trbJ+ clones in Pseudomonas aeruginosa strain PAO.

De Madres a Madres: a community, primary health care program based on empowerment

Based on the concepts of empowerment of indigenous women through unity, validation of women as key health promoters, and the acceptance of a community's ability to identify and redress its own health needs, the de Madres a Madres Program was started in a Houston inner-city Hispanic community. The program has become a strategy for mobilizing a total community for health. Indigenous volunteer mothers learned how to provide information to increase access to health care. Information was provided through community coalitions the mothers formed with health clinics, social service agencies, local businesses, schools, churches, elected officials, and the media. Outcome data identified the covert functions of the program to be the enhancement of individual women's self-esteem and power, and the collective enhancement of community self-esteem, power, and economy. The concept of a community economy and a theoretical basis of empowerment of women are discussed in terms of community empowerment for community health.

De Madres a Madres: women building community coalitions for health

How one group of Hispanic women in Houston, Texas, built community coalitions for primary health care is chronicled from the perspectives of the women. We describe how they formed partnerships with community businesses, health and social service agencies, schools, and churches to develop an outreach network that enables pregnant women to obtain early prenatal care. These women's steps in coalition building are related to feminist theory, with an emphasis on group decision making, shared power for the empowerment of all, and the creation of an environment in which individual worth and dignity are enhanced and risk taking is encouraged and supported.

Abuse during pregnancy: effects on maternal complications and birth weight in adult and teenage women

OBJECTIVE

To determine the incidence of physical and sexual abuse in a sample of adult and teen pregnant women and to determine the effect of abuse on birth weight.

METHODS

One thousand two hundred three African-American, Hispanic, and white urban female residents were screened for abuse on their first prenatal visit and in the second and third trimesters. Infant birth weight was obtained by record review.

RESULTS

Abuse during pregnancy was reported by 20.6% of teens and 14.2% of the adult women (P < .01). Both abused teens and adults were more likely than nonabused women to enter prenatal care in the third trimester (21.9 versus 7.5%, P = .001 for teens; 15.8 versus 8.7%, P = .007 for adults). For the aggregate sample of 1203 women, abuse during pregnancy was a significant (P < .05) risk for low birth weight (LBW), as well as low maternal weight gain, infections, anemia, smoking, and use of alcohol or drugs. Using Institute of Medicine risk factors for LBW, abused adults were at significantly greater risk for poor obstetric history, short inter-pregnancy interval, infections, anemia, smoking, and alcohol or drug usage. Abused teens had a significantly greater risk for poor weight gain, first- or second-trimester bleeding, smoking, and alcohol or drug use.

CONCLUSIONS

One in five teens and one in six adult women experienced abuse during pregnancy. Abuse is related to LBW and late entry into prenatal care. Abuse can be documented readily with a short abuse assessment screen and interventions then initiated.

Pornography and abuse of women

To study the association between male pornographic use and physical abuse of women, 87 battered women filing charges against their male partner at the district attorney's office in a large metropolitan city were surveyed. Forty percent reported that their male partner used one or more such materials. Use of the materials was significantly associated with the women being asked or forced to participate in violent sexual acts including rape.

The isolation of activin from ovine amniotic fluid

During a study of the levels of inhibin and follistatin in ovine amniotic fluid, we noted that although detectable levels of immunoactive inhibin and follistatin were found throughout gestation, the addition of amniotic fluid to a rat anterior pituitary cell culture resulted in a stimulation, rather than the expected suppression, of FSH concentrations. These data suggested the possibility that activin was present in amniotic fluid. We, therefore, set out to isolate the molecules responsible for this activin-like activity and determine their structure. Amniotic fluid, collected from pregnant sheep between 120-140 days gestation, was used as starting material in the purification and diluted in parallel to a human activin-A standard in the activin RIA employed to monitor the purification. A total pool of 7.4 liters amniotic fluid was processed by dye affinity chromatography, hydrophobic interactive chromatography, gel filtration, and a series of reverse phase HPLC steps. Polyacrylamide gel electrophoresis of fractions from the final HPLC step, which showed both activin immunoactivity and bioactivity, revealed a band with a mol wt of 25.3 kilodaltons (kDa), which reduced to 15.8 kDa, and a minor band of 45 kDa, which reduced to 25 kDa. NH2-terminal amino acid sequences of several active fractions from the same region were identical to the known sequence of ovine activin-A. The identification of immunoactive activin, follistatin, and inhibin in amniotic fluid raises the question of the sites of production of these proteins and their interactions and role in fetal physiology.

Induction chemotherapy followed by breast conservation for locally advanced carcinoma of the breast

BACKGROUND

Few women with locally advanced breast cancer remain disease-free, even for 2 years. Response to induction chemotherapy may be associated with longer disease-free and overall survival rates. The role of breast conservation in selected patients with response to induction chemotherapy was evaluated.

METHODS

Since 1979, patients with Stages IIB and III breast cancer have undergone induction chemotherapy; patients with response continued chemotherapy until a plateau of regression was achieved. Before 1983, all patients having a response to chemotherapy underwent mastectomy; since 1983, selected patients have undergone breast conservation. Outcomes were tallied comparing these two groups of patients.

RESULTS

The study group included 189 women, who were followed up for 12-159 months (median, 46 months) after diagnosis. Of the patients, 85% had a response to induction chemotherapy. Patients with no response were excluded from additional consideration in this study. One hundred three (64%) women underwent mastectomy; 55 (36%) were treated with breast conservation. The disease-free 5-year survival rate was 61% for all patients with a response to chemotherapy; 56% for those having mastectomy and 77% for those having breast conservation. The overall 5-year survival rate was 69% for all patients with a response to chemotherapy, 67% for those undergoing mastectomy and 80% for those having breast conservation.

CONCLUSIONS

Induction chemotherapy achieves significant tumor regression in most women with locally advanced breast cancer, permitting subsequent breast conservation or mastectomy with a greater expectation of long-term success. Breast conservation is used more frequently with the same expectation of success as mastectomy, presuming careful selection based on response to chemotherapy.

Physical and emotional abuse in pregnancy: a comparison of adult and teenage women

A sample of 691 African American, Hispanic, and white pregnant teenage and adult women were interviewed in the prenatal setting. On their first prenatal visit, 182 (26%) women reported physical or sexual abuse within the past year. There were significant differences between the teens and adults, with a higher percentage of teens (31.6%) reporting abuse during the prior year than adults (23.6%). The rate of abuse during pregnancy was 21.7% for teens and 15.9% for adult women. Adult women scored significantly higher than teens on two measures of mental abuse. Mental abuse was significantly correlated with physical abuse for all subjects.

Community health organizing: whom are we empowering?

Current strategies for initiating and operating community health programs rely on one of two approaches. One is a predetermined, operational process. The other comes from the grassroots, beginning with involvement of the recipients of the program. This editorial chronicles how one grassroots program, begun by volunteer mothers and one community health nurse, developed into a partnership for primary health care that advocates and empowers the entire community. In the end, the editorial challenges community health organizers to ask whom their programs are empowering--the community or the organizers themselves?

Assessing for abuse during pregnancy. Severity and frequency of injuries and associated entry into prenatal care

OBJECTIVE

To assess the occurrence, frequency, and severity of physical abuse during pregnancy and associated initiation of prenatal care.

DESIGN

Stratified, prospective cohort analysis.

SETTING

Public prenatal clinics in Houston, Tex, and Baltimore, Md.

PARTICIPANTS

Total population-based sample of 691 black, Hispanic, and white pregnant women. All of the women were urban residents and most of the Hispanic women were Mexican American. All participants were invited into the study at the first prenatal visit and were followed up until delivery.

MAIN OUTCOME MEASURE

Identification of abuse status.

RESULTS

A three-question Abuse Assessment Screen detected a 17% (1/6) prevalence of physical or sexual abuse during pregnancy, which is more than double all previous published reports. When evaluated against nationally tested research instruments, the three-question screen that was asked at the first prenatal visit was sensitive and specific to abuse status. Abuse was recurrent, with 60% of abused women reporting two or more episodes of assault. Location of abuse focused on the head. Frequency and severity of abuse and potential danger of homicide was appreciably worse for white women. Abused women were twice as likely as nonabused women to begin prenatal care during the third trimester.

CONCLUSIONS

A simple clinical assessment screen completed by the health care provider in a private setting and with the male partner absent is as effective as research instruments in identifying abused women. Straightforward, routine clinical assessment is recommended as essential in preventing potential trauma, interrupting existing abuse, and protecting health.