Identifying intimate partner violence at entry to prenatal care: clustering routine clinical information

Antepartum Intimate Partner Violence: Development of a Risk Prediction Model

Objectives: To explore socio-behavioral, clinical, and imaging findings associated with antepartum intimate partner violence (IPV) and aid in risk stratification of at-risk individuals. Methods: We analyzed electronic medical records during indexed pregnancies for 108 pregnant patients who self-reported antepartum IPV (cases) and 106 age-matched pregnant patients who did not self-report antepartum IPV (controls). Sociodemographic, clinical, and radiology data were analyzed via chi-squared and Fisher's exact tests with p < 0.05 as the threshold for significance. Stepwise logistic regression was applied to derive a risk prediction model. Results: The proportion of cases reporting emotional IPV (76% vs. 52%) and/or physical IPV (45% vs. 31%) during pregnancy significantly increased from prior to pregnancy. Cases were significantly more likely to report prepregnancy substance use (odds ratio [OR] = 2.60; 95% confidence interval [CI]: 1.13-5.98), sexually transmitted infections (OR = 3.48; 95%CI: 1.64-7.37), abortion (OR = 3.17; 95%CI: 1.79, 5.59), and preterm birth (OR = 5.97; 95%CI: 1.69-21.15). During pregnancy, cases were more likely to report unstable housing (OR = 5.26; 95%CI: 2.67-10.36), multigravidity (OR = 2.83; 95%CI: 1.44-5.58), multiparity (OR = 3.75; 95%CI: 1.72-8.20), anxiety (OR = 3.35; 95%CI: 1.85-6.08), depression (OR = 5.58; 95%CI: 3.07-10.16), substance use (OR = 2.92; 95%CI: 1.28-6.65), urinary tract infection (UTI) (OR = 3.26; 95%CI: 1.14-9.32), intrauterine growth restriction (OR = 10.71; 95%CI: 1.35-85.25), and cesarean delivery (OR = 2.25; 95%CI: 1.26-4.02). Cases had significantly more OBGYN abnormalities on imaging and canceled more radiological studies (OR = 5.31). Logistic regression found housing status, sexually transmitted infection history, preterm delivery history, abortion history, depression, and antepartum UTI predictive of antepartum IPV. The risk prediction model achieved good calibration with an area under the curve of 0.79. Conclusions: This study identifies significant disparities among patients experiencing antepartum IPV, and our proposed risk prediction model can inform risk assessment in this setting.

Structural Relationship Model of Basic Psychological Needs With Intimate Partner Violence: The Mediating Role of Gender Discrimination and Self-Esteem

Intimate partner violence (IPV) encompasses a range of abusive behaviors within intimate relationships. This study examines the structural relationships between basic psychological needs and IPV victimization among Iranian women, shedding light on the complex factors contributing to IPV and potential avenues for intervention. Data were gathered from a sample of 306 Iranian women who had experienced IPV, utilizing the Domestic Violence Questionnaire, the Basic Psychological Need Satisfaction Scale, the Ambivalent Sexism Inventory, and the Rosenberg Self-Esteem Scale. The findings supported the appropriate fit of the proposed model and revealed that basic psychological needs exerted significant direct and indirect effects on IPV victimization, mediated through self-esteem and ambivalent sexism. These results provide valuable new insights into the complex dynamics of IPV victimization and hold promise for the development of targeted interventions aimed at preventing IPV and supporting the well-being of affected individuals. Furthermore, the interpretation of the findings has been revised to avoid any implication of victim-blaming, aligning with the aim of understanding and addressing the structural factors contributing to IPV victimization.

Intimate partner violence and barriers to prenatal care

RATIONALE

Past research has shown that intimate partner violence (IPV) is associated with less adequate access to prenatal care. However, less is known about why IPV creates challenges for accessing prenatal care, including how IPV is related to unique barriers to prenatal care.

OBJECTIVE

The aim of this study is to examine the association between physical IPV around the time of pregnancy (preconception IPV, prenatal IPV, or both preconception and prenatal IPV) and (1) adequacy of prenatal care, and (2) barriers to prenatal care.

METHODS

Data are from 35 sites (34 states and New York City) from the Pregnancy Risk Assessment Monitoring System (PRAMS) for years 2009-2016 (n = 166,840). Adequacy of prenatal care is examined using multinomial logistic regression and measures of barriers to prenatal care are assessed using negative binomial regression and logistic regression.

RESULTS

The findings reveal that women with IPV exposure-especially those who experience IPV both before and during pregnancy-are more likely to experience inadequate prenatal care. In addition, women with IPV exposure incur a higher rate of barriers to prenatal care, as well as several specific barriers to prenatal care including not having transportation, not being able to get time off work, being too busy, being unable to find child care, and keeping a pregnancy a secret.

CONCLUSIONS

Considering the adverse consequences of both IPV and inadequate access to prenatal care for maternal and child health, the findings of this study highlight the need for public health interventions that both reduce the prevalence of IPV and remove barriers to prenatal care for IPV-exposed women.

Pregnant Victims of Intimate Partner Homicide in the National Violent Death Reporting System Database, 2003-2014: A Descriptive Analysis

Intimate partner homicide (IPH) is a leading cause of maternal mortality in the United States. However, very little information exists as to the circumstantial factors associated with IPH during pregnancy. We conducted a descriptive study of the demographic characteristics, psychosocial service engagement, and crises experiences (i.e., life and relationship stressors) among pregnant and nonpregnant victims to understand what differences, if any, exist in their risk profile for IPH. Data from the Centers for Disease Control and Prevention's National Violent Death Reporting System (NVDRS) were used for this study. The NVDRS is a national opt-in tracking system of all violent deaths in the United States. Pregnant victims (N = 293) were significantly more likely to be 5 years younger than nonpregnant victims, African American, and never married. Pregnant victims were more likely to be seen in the emergency room following the fatal incident. Nonpregnant victims (N = 2,089) were significantly more likely to have suspected alcohol use at the time of their death. In strictly proportional terms, we also observed higher rates of mental health problems, a history of mental health treatment, and a reported history of intimate partner violence (IPV), crisis, or family problems among nonpregnant victims. A wider range of IPH-related risk factors (e.g. substance abuse) need to be included IPV assessments. Future studies should seek to develop effective interventions to prevent IPH, particularly among reproductive aged women.

Validity of the ACTS intimate partner violence screen in antenatal care: a cross sectional study

Background

Intimate partner violence (IPV) is a major public health problem with harmful consequences. In Australia, there is no national standard screening tool and screening practice is variable across states. The objectives of this study were to assess in the antenatal healthcare setting: i) the validity of a new IPV brief screening tool and ii) women’s preference for screening response format, screening frequency and comfort level.

Methods

One thousand sixty-seven antenatal patients in a major metropolitan Victorian hospital in Australia completed a paper-based, self-administered survey. The survey included four screening items about whether they were Afraid/Controlled/Threatened/Slapped or physically hurt (ACTS) by a partner or ex-partner in the last 12 months; and the Composite Abuse Scale (reference standard). The ACTS screen was presented firstly with a binary yes/no response format and then with a five-point ordinal frequency format from ‘never’ (0) to ‘very frequently’ (4). The main outcome measures were test statistics of the four-item ACTS screening tool (sensitivity, specificity, predictive values, and area under the curve) against the reference standard and women’s screening preferences.

Results

Twelve-month IPV prevalence varied depending on the ACTS response format with 8% (83) positive on ACTS yes/no format, 12.8% (133) positive on ACTS ordinal frequency format and 10.5% (108) on the reference Composite Abuse Scale. Overall, the ACTS screening tool demonstrated clinical utility for the ordinal frequency format (AUC, 0.80; 95% CI = 0.76 to 0.85) and the binary yes/no format (AUC, 0.74, 95% CI = 0.69 to 0.79). The frequency scale (66%) had greater sensitivity than the yes/no scale (51%). The positive and negative predictive values were 56 and 96% for the frequency scale and 68 and 95% for the yes/no scale. Specificity was high regardless of screening question response options. Half (53%) of the women categorised as abused preferred the yes/no scale. Around half of the women (48%, 472) thought health care providers should ask pregnant women about IPV at every visit.

Conclusions

The four-item ACTS tool (using the frequency scale and a cut-off of one on any item) is recommended for written self-administered screening of women to identify those experiencing IPV to enable first-line response and follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11781-x.

Social determinants of health: the how, who, and where screenings are occurring; a systematic review

Screening for social determinants of health allows health care teams to assess and address social factors that influence one's health, mental health, and access to care. These social factors include poverty, health literacy, social support, exposure to trauma, food insecurity, and housing instability. The objective of this study was to examine what screening tools for social determinants of health are being used, in what contexts, and with what populations. Findings suggest that health literacy is the most commonly screened for, followed by trauma history, social support, food insecurity and housing across diverse contexts and populations. Results from this study can be used to inform providers of available screening tools and resources that can be readily utilized in practice.

Intimate Partner Violence Before and During Pregnancy, and Prenatal Counseling Among Women with a Recent Live Birth, United States, 2009-2015

Background: Intimate partner violence (IPV) is a leading cause of injury for reproductive-aged women. Clinical guidelines exist to assist providers in counseling women for IPV, but information on provider counseling among pregnant women from population-based sources is limited. Materials and Methods: Data for 2009-2015 from 37 states and New York City participating in the Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed (n = 258,263). We compared prevalence estimates overall and by site, of physical IPV occurring before and/or during pregnancy, and prenatal counseling on physical IPV. Multivariable logistic regression was used to identify factors associated with receiving prenatal counseling on physical IPV. Results: Overall, 3.8% of women reported experiencing any physical IPV in the 12 months before and/or during pregnancy (range: 1.5% [Connecticut] to 7.2% [Mississippi]). Prevalence of prenatal IPV counseling was 51.0% (range: 30.2% [Utah] to 63.1% [New Mexico]). Receipt of prenatal counseling on depression predicted a fourfold increase in prevalence of receiving counseling on physical IPV (adjusted prevalence ratio [aPR] = 4.20, 95% confidence interval [CI]: 4.06-4.34). In addition, non-Hispanic black race versus non-Hispanic white race, and having less than a high school education were associated with higher prevalence of receipt of IPV counseling ([aPR = 1.16, 95% CI: 1.14-1.18] and [aPR = 1.11, 95% CI: 1.08-1.13], respectively). Conclusion: Almost 4% of women with a recent live birth reported physical IPV before and/or during pregnancy. Only half of women received counseling on IPV during prenatal care, with counseling rates varying widely among states. Increased adherence to guidelines for universal screening and counseling of women could ensure all women are offered appropriate support and referral.

Opportunistic domestic violence screening for pregnant and post-partum women by community based health care providers

Background

Domestic violence against women is a global endemic that can commence or escalate during pregnancy and continue postpartum. Pregnant and postpartum women generally access health care providers more at this time than at any other time in their lives. Despite this, little is known about primary health care providers’ screening practices for domestic violence. The purpose of this paper is to present survey findings that identified domestic violence screening practices of community based health care providers in pregnant and postpartum women.

Methods

This paper reports on the survey results of a larger sequential mixed methods study that involved a survey and semi-structured interviews, and used a pragmatic approach to the data collection and analysis. The survey sought information via both fixed choice and open responses. Quantitative data from the surveys were entered into the Statistical Package for Social Science (SPSS™ Version 22) and analysed using descriptive statistics. Open responses were collated and then integrated and presented with the quantitative data.

Results

Results revealed that some health care providers did not screen for domestic violence. Factors contributing to this lack of screening included: a lack of recognition that this was part of their role; and a lack of domestic violence screening policies and/or reminder systems. Further barriers to domestic violence screening were identified as a lack of time, resources and confidence in undertaking the screening and referral of women when domestic violence was detected.

Conclusions

The findings reported in this paper confirm that further insights into the domestic violence screening practices of community based health care providers is required. Findings also have the potential to inform interventions that can be implemented to increase domestic violence screening and promote appropriate referral practices.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0620-2) contains supplementary material, which is available to authorized users.

The relationship between intimate partner violence reported at the first antenatal booking visit and obstetric and perinatal outcomes in an ethnically diverse group of Australian pregnant women: a population-based study over 10 years

OBJECTIVES

Intimate partner violence (IPV) is a global health issue affecting mainly women and is known to escalate during pregnancy and impact negatively on obstetric and perinatal outcomes. The aim of this study is to determine the incidence of IPV in a pregnant multicultural population and to determine the relationship between IPV reported at booking interview and maternal and perinatal outcomes.

DESIGN

This is a retrospective population-based data study. We analysed routinely collected data (2006-2016) from the ObstetriX system on a cohort of pregnant women.

SETTING AND PARTICIPANTS

33 542 women giving birth in a major health facility in Western Sydney.

PRIMARY OUTCOMES

Incidence of IPV, association with IPV and other psychosocial variables and maternal and perinatal outcomes.

RESULT

4.3% of pregnant women reported a history of IPV when asked during the routine psychosocial assessment. Fifty-four per cent were not born in Australia, and this had increased significantly over the decade. Women born in New Zealand (7.2%) and Sudan (9.1%) were most likely to report IPV at the antenatal booking visit, with women from China and India least likely to report IPV. Women who reported IPV were more likely to report additional psychosocial concerns including Edinburgh Postnatal Depression Scale scores > 13 (7.6%), thoughts of self-harm (2.4%), childhood abuse (23.6%), and a history of anxiety and depression (34.2%). Women who reported IPV were more likely to be Australian born, smoke and be multiparous and to have been admitted for threatened preterm labour (Adjusted Odds Ratio (AOR) 1.8, 95% CI 1.28 to 2.39).

CONCLUSIONS

A report of IPV at the first antenatal booking visit is associated with a higher level of reporting on all psychosocial risks, higher antenatal admissions, especially for threatened preterm labour. More research is needed regarding the effectiveness of current IPV screening for women from other countries.

Exploring the associations between intimate partner violence victimization during pregnancy and delayed entry into prenatal care: Evidence from a population-based study in Bangladesh

OBJECTIVE

Intimate partner violence (IPV) during pregnancy can have serious health consequences for mothers and newborns. The aim of the study is to explore: 1) the influence of experiencing IPV during pregnancy on delayed entry into prenatal care; and 2) whether women's decision-making autonomy and the support for traditional gender roles act to mediate or moderate the relationship between IPV and delayed entry into prenatal care.

DESIGN

cross-sectional survey. Multivariate logistic regression models were estimated that control for various socio-demographic and pregnancy related factors to assess whether women who experienced IPV during pregnancy were more likely to delay entry into prenatal care compared with women who had not experienced IPV. The influence of traditional gender roles acceptance and decision-making autonomy were examined both as independent variables and in interaction with IPV, to assess their role as potential mediators or moderators.

SETTING

Chandpur district, Bangladesh.

PARTICIPANTS

the sample comprised of 426 Bangladeshi women, aged 15-49 years. Postpartum mothers who visited vaccinations centres to receive their children's vaccinations constitute the sampling frame.

RESULTS

almost 70% of the women surveyed reported patterns consistent with delayed entry into prenatal care. Accounting for the influence of other covariates, women who experienced physical IPV during pregnancy were 2.61 times more likely (95% CI [1.33, 5.09]) to have delayed entry into prenatal care than their counterparts who did not report physical IPV. Neither sexual nor psychological IPV victimization during pregnancy was linked with late entry into prenatal care. Both gender role attitudes and levels of autonomy mediate the effect of IPV on prenatal care.

KEY CONCLUSIONS

the results suggest that the high rates of IPV in Bangladesh have effects that can compromise women's health seeking behaviour during pregnancy, putting them and their developing fetus at risk. Specifically, Bangladeshi women who experience physical IPV during pregnancy are more likely to delay or forgo prenatal care, an effect that is further magnified by cultural ideals that emphasize women's traditional roles and limit their autonomy.

IMPLICATIONS FOR PRACTICE

this study reinforces the need to detect and assist women suffering IPV, not only to offer them help and support but also to increase entry into prenatal care. Healthcare professionals involved in obstetrics and midwifery need to be aware of the risk factors of IPV during pregnancy and be able to identify women who are at risk for delayed entry into prenatal care.

Incidence of Domestic Violence Against Pregnant Females After the Great East Japan Earthquake in Miyagi Prefecture: The Japan Environment and Children's Study

OBJECTIVE

This study aimed to clarify the correlation between the 2011 Great East Japan Earthquake and domestic violence (DV) against pregnant females after the disaster in Miyagi Prefecture, an area damaged by the earthquake and tsunami.

METHODS

We analyzed 7600 pregnant females from June to December 2011. The incidence of physical and mental DV and the proportions in the inland, north coastal, and south coastal areas of Miyagi Prefecture and nationwide were calculated, and a chi-square test was conducted for comparison. The risk factors for DV were estimated with multivariate logistic regression analyses on a prefecture-wide basis.

RESULTS

The incidence levels for physical DV were found to be 5.9% in the north coastal area, which was significantly higher than in the inland area (1.3%, P=0.0007) and nationwide (1.5%, P<0.0001). There were no significant differences in the incidence of mental DV between the 3 areas in Miyagi Prefecture (inland 15.2%, north coast 15.7%, and south coast 18.8%) or nationwide (13.8%). Experiencing disease or injury in someone close and changes in the family structure were significantly associated with mental DV in Miyagi Prefecture.

CONCLUSION

Continuous monitoring and support for pregnant females may be necessary to address this issue in disaster-affected areas. (Disaster Med Public Health Preparedness. 2017;11:216-226).

Measures for screening for intimate partner violence: a systematic review

WHAT IS KNOWN ON THE SUBJECT?: Intimate partner violence (IPV) has a significant impact on the onset, duration and recurrence of mental health problems. Prevalence rates of IPV are significantly higher in mental health services, but the studies are limited. Accurate assessment of IPV is important for decision making in risk assessment and safety planning within mental health nursing. Psychometrically tested tools are the most accurate way to identifying all areas of IPV abuse: physical, sexual and psychological. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Ten IPV screening tools were identified in healthcare and three tools; Women Abuse Screen Tool (WAST), Abuse Assessment Screen (AAS) and Humiliation, Afraid, Rape and Kick (HARK) were identified as having strong psychometric values as they assessed all areas of IPV and were validated against an appropriate reference standard. None of the three IPV tools identified (WAST, AAS, HARK) were tested on men or in mental health settings impacting the gender sensitivities of the tools and the reliability of the prevalence rates of IPV in mental healthcare. Over seventy percent of the studies reviewed were conducted in America this impacts the cultural sensitivities of the IPV tools. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: IPV screening needs to be incorporated as a priority in mental health services in order to reduce the morbidity and mortality issues associated with this abuse. Psychometric tools to screen for IPV need to be incorporated to assist mental health professionals in decision making in risk assessment and safety planning. Further research is needed to improve the psychometric properties of IPV tools in mental health settings, to ensure they are culturally and gender sensitive.

ABSTRACT

Objective Intimate partner violence (IPV) is a public health priority due to the physical and mental impacts it has on health. No existing reviews have focused on the psychometric properties of IPV screening tools used to screen men and women within a mental health context. This review aimed to identify the best psychometrically tested screening tools available to assess all areas of IPV in men and women in mental health setting. Method Databases psycArticles, PsycINFO, Social Science, CINAHL, PubMed and Cochrane were searched from their starting date through to July 2015. Eligible studies were published in peer-reviewed publications in English. Results Thirty-six studies met the inclusion criteria. Ten IPV screening tools were identified. Three tools assessed all areas of IPV and were validated against an appropriate reference standard. One study tested IPV screening tool in a mental health setting. Conclusion Mental health nurses need to incorporate a psychometrically tested IPV tool as part of risk assessment and safety planning for clients. This review identified three tools that are suitable for identifying IPV in a mental health context. However, further research is necessary to validate IPV screening tools that are culturally sensitive and have been validated with men and women.

Cross-sectional and longitudinal risk of physical impairment in a cohort of postmenopausal women who experience physical and verbal abuse

BACKGROUND

Exposure to interpersonal violence, namely verbal and physical abuse, is a highly prevalent threat to women's health and well-being. Among older, post-menopausal women, several researchers have characterized a possible bi-directional relationship of abuse exposure and diminished physical functioning. However, studies that prospectively examine the relationship between interpersonal abuse exposure and physical functioning across multiple years of observation are lacking. To address this literature gap, we prospectively evaluate the association between abuse exposure and physical functioning in a large, national cohort of post-menopausal women across 12 years of follow-up observation.

METHODS

Multivariable logistic regression was used to measure the adjusted association between experiencing abuse and physical function score at baseline in 154,902 Women's Health Initiative (WHI) participants. Multilevel modeling, where the trajectories of decline in physical function were modeled as a function of time-varying abuse exposure, was used to evaluate the contribution of abuse to trajectories of physical function scores over time.

RESULT

Abuse was prevalent among WHI participants, with 11 % of our study population reporting baseline exposure. Verbal abuse was the most commonly reported abuse type (10 %), followed by combined physical and verbal abuse (1 %), followed by physical abuse in the absence of verbal abuse (0.2 %). Abuse exposure (all types) was associated with diminished physical functioning, with women exposed to combined physical and verbal abuse presenting baseline physical functioning scores consistent with non-abused women 20 years senior. Results did not reveal a differential rate of decline over time in physical functioning based on abuse exposure.

CONCLUSIONS

Taken together, our findings suggest a need for increased awareness of the prevalence of abuse exposure among postmenopausal women; they also underscore the importance of clinician's vigilance in their efforts toward the prevention, early detection and effective intervention with abuse exposure, including verbal abuse exposure, in post-menopausal women. Given our findings related to abuse exposure and women's diminished physical functioning at WHI baseline, our work illuminates a need for further study, particularly the investigation of this association in younger, pre-menopausal women so that the temporal ordering if this relationship may be better understood.

Intimate partner violence during pregnancy: maternal and neonatal outcomes

The effects of intimate partner violence (IPV) on maternal and neonatal outcomes are multifaceted and largely preventable. During pregnancy, there are many opportunities within the current health care system for screening and early intervention during routine prenatal care or during episodic care in a hospital setting. This article describes the effects of IPV on maternal health (e.g., insufficient or inconsistent prenatal care, poor nutrition, inadequate weight gain, substance use, increased prevalence of depression), as well as adverse neonatal outcomes (e.g., low birth weight [LBW]), preterm birth [PTB], and small for gestational age [SGA]) and maternal and neonatal death. Discussion of the mechanisms of action are explored and include: maternal engagement in health behaviors that are considered "risky," including smoking and alcohol and substance use, and new evidence regarding the alteration of the hypothalamic-pituitary-adrenal axis and resulting changes in hormones that may affect LBW and SGA infants and PTB. Clinical recommendations include a commitment for routine screening of IPV in all pregnant women who present for care using validated screening instruments. In addition, the provision of readily accessible prenatal care and the development of a trusting patient-provider relationship are first steps in addressing the problem of IPV in pregnancy. Early trials of targeted interventions such as a nurse-led home visitation program and the Domestic Violence Enhanced Home Visitation Program show promising results. Brief psychobehavioral interventions are also being explored. The approach of universal screening, patient engagement in prenatal care, and targeted individualized interventions has the ability to reduce the adverse effects of IPV and highlight the importance of this complex social disorder as a top priority in maternal and neonatal health.

Factors associated with domestic violence: a cross-sectional survey among women in Jeddah, Saudi Arabia

OBJECTIVE

This study aims to identify the factors associated with domestic violence (DV) among women in Jeddah.

DESIGN

Cross-sectional survey.

SETTING

Outpatient departments of three tertiary hospitals in Jeddah.

PARTICIPANTS

Convenience sample of women, aged 15-70 years, at the outpatient and inpatient clinics.

INTERVENTIONS

Between 15 December 2011 and 30 May 2012, a psychologist and a professional health assistant explained the purpose of the research to participants, who were then asked to fill a 50-item questionnaire. The questionnaire was created based on questions from three questionnaires: the NorVold Domestic Abuse Questionnaire, the Pregnancy Risk Assessment Monitoring System and the Kansas Marital Satisfaction Scale. The questionnaire was used to assess the association between DV and family status, male partner attitudes, age, educational attainment, employment, financial and socioeconomic status.

RESULTS

A total of 2301 women participated in the survey (81% response rate). The mean±SD age of the participants was 34.4±10.9 years. The lifetime prevalence of DV was 34%. Abused women had more children than non-abused women (p=0.001), and their spouses were significantly older than those of non-abused women (p<0.0001). Financially dependent women and those with a high educational status were significantly more likely to report abuse (p=0.003 and p<0.001, respectively). Abused women were also likely to report that their spouse was a smoker (p<0.0001) and had completed at least primary or secondary education (p<0.0001). A significantly lower proportion of abused women reported that their male partners were alcohol users (p=0.001). The results of logistic regression showed that women who were financially dependent had about 1.5-fold odds of being physically abused by a spouse.

CONCLUSIONS

Many factors are associated with DV against women, thereby highlighting the need to design effective DV prevention programmes.

Maternal and fetal outcomes of intimate partner violence associated with pregnancy in the Latin American and Caribbean region

BACKGROUND

Very high rates of intimate partner violence during pregnancy (IPV-P) are reported in Latin America and the Caribbean (LAC) but data on prevalence and obstetric-related outcomes are limited.

OBJECTIVES

To conduct a literature review on risk factors, prevalence, and adverse obstetric-related outcomes of IPV-P in LAC.

SEARCH STRATEGY

Systematic review of studies in MEDLINE (1946-2012) and LILACS (1982-2012), and hand searching of reference lists of included studies. Search terms were variations of partner abuse and pregnancy in LAC.

SELECTION CRITERIA

Studies were excluded if they did not include IPV-P prevalence or if the perpetrator was not an intimate partner.

DATA COLLECTION AND ANALYSIS

Study quality was assessed via US Preventive Services Task Force criteria.

MAIN RESULTS

In the 31 studies included, prevalence rates ranged from 3% to 44%. IPV-P was significantly associated with unintended pregnancies and adverse maternal (depression, pregnancy-related symptom distress, inadequate prenatal care, vaginal bleeding, spontaneous abortion, gestational weight gain, high maternal cortisol, hypertension, pre-eclampsia, STIs) and infant (prematurity, low birth weight, neonatal complications, stillbirth) outcomes (grade II-2 and 3 evidence).

CONCLUSIONS

IPV-P is highly prevalent in LAC, with poor obstetric-related outcomes. Clinicians must identify women experiencing IPV-P and institute appropriate interventions and referrals to avoid its deleterious consequences.

Intimate partner violence, substance use, and adverse neonatal outcomes among urban women

OBJECTIVE

To assess the prevalence of intimate partner violence, substance use, and their co-occurrence during pregnancy and to examine their associations with adverse neonatal outcomes.

STUDY DESIGN

Between February 2009-February 2010, pregnant women receiving obstetrical care at 3 urban clinics were screened for intimate partner violence and substance use between 24-28 weeks gestation. A chart review was conducted upon delivery to assess for adverse neonatal outcomes of low birth weight, preterm birth, and small for gestational age (SGA).

RESULTS

Maternal and neonatal data were collected on 166 mothers and their neonates. Overall, 19% of the sample reported intimate partner violence during their pregnancies. Of the study's neonates, 41% had at least 1 adverse neonatal outcome. Nearly one-half of the mothers reported using at least 1 substance during pregnancy. Women experiencing intimate partner violence had a higher prevalence of marijuana use than their nonabused counterparts (P < .01). Experiencing intimate partner violence was associated with a 4-fold increase in having a SGA neonate (aOR = 4.00; 95% CI 1.58-9.97). Women who reported marijuana use had 5 times the odds of having a neonate classified as SGA (aOR = 5.16, 95% CI 2.24-11.89) or low birth weight (aOR 5.00; 95% CI 1.98-12.65).

CONCLUSIONS

The prevalence of intimate partner violence during pregnancy and substance use is high in urban mothers, the risks of which extend to their neonates. Pediatric providers are urged to routinely screen for both issues and recognize the impact of co-occurrence of these risk factors on poor neonatal and childhood outcomes.

A Community-Supported Clinic-Based Program for Prevention of Violence against Pregnant Women in Rural Kenya

Objective. Pregnant women are especially vulnerable to adverse outcomes related to HIV infection and gender-based violence (GBV). We aimed at developing a program for prevention and mitigation of the effects of GBV among pregnant women at an antenatal clinic in rural Kenya. Methods. Based on formative research with pregnant women, male partners, and service providers, we developed a GBV program including comprehensive clinic training, risk assessments in the clinic, referrals supported by community volunteers, and community mobilization. To evaluate the program, we analyzed data from risk assessment forms and conducted focus groups (n = 2 groups) and in-depth interviews (n = 25) with healthcare workers and community members. Results. A total of 134 pregnant women were assessed during a 5-month period: 49 (37%) reported violence and of those 53% accepted referrals to local support resources. Qualitative findings suggested that the program was acceptable and feasible, as it aided pregnant women in accessing GBV services and raised awareness of GBV. Community collaboration was crucial in this low-resource setting. Conclusion. Integrating GBV programs into rural antenatal clinics has potential to contribute to both primary and secondary GBV prevention. Following further evaluation, this model may be deemed applicable for rural communities in Kenya and elsewhere in East Africa.

Intimate partner violence during pregnancy: best practices for social workers

Intimate partner violence (IPV) during pregnancy is a major problem in the United States, with estimates that 3 percent to 17 percent of women experience violence during the perinatal period. Research indicates that IPV during pregnancy is associated with serious, negative health outcomes for the mother and her unborn child. As such, many researchers have suggested that pregnancy offers a unique window for IPV intervention, particularly for social workers in health-care settings. Although assessing for IPV more generally has received increased attention in the social work literature, there is a lack of information about the specific needs for pregnant women. Thus, the purpose of this article is to provide a focused literature review on the scope and impact of IPV during pregnancy and to identify best practices for social workers for intervention and prevention.

Depression during pregnancy: prevalence and risk factors among women attending a public health clinic in Rio de Janeiro, Brazil

Depression is the most prevalent psychiatric disorder during pregnancy and is associated with psychosocial and clinical obstetric factors. Despite being an important public health issue, there are few studies about this issue in Brazil. A cross-sectional study was carried out, involving 331 pregnant women attending a public primary health service over a one-year period in Rio de Janeiro city, Brazil. Participants were interviewed about their socio-demographic status, obstetric/medical conditions, life events and violence during pregnancy. Depression was assessed using the Composite International Development Interview. The prevalence of depression during pregnancy was 14.2% (95%CI: 10.7-18.5) and associated factors included: previous history of depression and any psychiatric treatment, unplanned pregnancy, serious physical illness and casual jobs. These data emphasize the need for screening for depression and its risk factors during pregnancy in settings where care is available. Psychosocial interventions and social policies need to be devised for this population.

Intimate partner violence as a risk factor for postpartum depression among Canadian women in the Maternity Experience Survey

PURPOSE

Intimate partner violence is a worldwide public health concern that predominantly affects women of reproductive age. The purpose of this study was to evaluate the effect of exposure to intimate partner violence before, during, or after pregnancy on postpartum depression in a nationally representative sample of Canadian women.

METHODS

A cross-sectional analysis was performed with the use of data from the Maternity Experience Survey conducted by Statistics Canada in 2006. A population-based sample of 8542 women 15 years and older who delivered singleton live births was selected from all Canadian provinces and territories; of those, 6421 completed a computer-assisted telephone interview. Recent experiences with and threats of physical or sexual violence by an intimate partner were examined in relation to postpartum depression assessed through the Edinburgh Postpartum Depression Scale.

RESULTS

The prevalence of postpartum depression was 7.5% (95% confidence interval, 6.8-8.2). Controlling for confounders, odds of postpartum depression were significantly greater among women who reported partner violence in the past two years as opposed to those who did not (adjusted odds ratio, 1.61; 95% confidence interval, 1.06-2.45).

CONCLUSIONS

Intimate partner violence is positively associated with postpartum depression among Canadian women. Implications for healthcare practice are discussed.

Screening and intervention for domestic violence during pregnancy care: a systematic review

Domestic violence (DV) against women during pregnancy affects many women and unborn infants worldwide. Pregnancy presents a window of opportunity for health care providers to identify DV and provide appropriate intervention. The aim of this systematic review was to appraise the effectiveness of DV screening and interventions for women identified for DV through screening in pregnancy. The Cochrane Library, EMBASE, MEDLINE, and PsycINFO were searched from January 1995 to November 2009 to identify potentially relevant studies. Studies using any comparative methodology from both national and international arenas were included but had to be in the English language. Nine studies (13 references) met the inclusion criteria, five for screening and four for interventions. Of the five screening studies, the identification of DV was significantly higher compared to studies that used a nonstandardized screen or no screen at all. There was also evidence that recurrent screening throughout the pregnancy further increased identification rates. There was some evidence that interventions for pregnant women who had experienced DV reduced the amount of violence experienced by these women, but the evidence is very limited by the small number of randomized studies with small participant numbers. Further research is required to establish the most effective interventions for women who are identified at risk of DV during pregnancy.

Partner violence during pregnancy: prevalence, effects, screening, and management

The purpose of this review is to provide an overview of the current state of knowledge regarding the experience of intimate partner violence (IPV) during pregnancy. Pregnancy IPV is a significant problem worldwide, with rates varying significantly by country and maternal risk factors. Pregnancy IPV is associated with adverse newborn outcomes, including low birth weight and preterm birth. Many mechanisms for how IPV may impact birth outcomes have been proposed and include direct health, mental health, and behavioral effects, which all may interact. Screening for IPV during pregnancy is essential, yet due to time constraints and few clear recommendations for assessment, many prenatal providers do not routinely inquire about IPV, or even believe they should. More training is needed to assist health care providers in identifying and managing pregnancy IPV, with additional research needed to inform effective interventions to reduce the rates of pregnancy IPV and resultant outcomes.

Health-sector responses to intimate partner violence in low- and middle-income settings: a review of current models, challenges and opportunities

There is growing recognition of the public-health burden of intimate partner violence (IPV) and the potential for the health sector to identify and support abused women. Drawing upon models of health-sector integration, this paper reviews current initiatives to integrate responses to IPV into the health sector in low- and middle-income settings. We present a broad framework for the opportunities for integration and associated service and referral needs, and then summarize current promising initiatives. The findings suggest that a few models of integration are being replicated in many settings. These often focus on service provision at a secondary or tertiary level through accident and emergency or women's health services, or at a primary level through reproductive or family-planning health services. Challenges to integration still exist at all levels, from individual service providers' attitudes and lack of knowledge about violence to managerial and health systems' challenges such as insufficient staff training, no clear policies on IPV, and lack of coordination among various actors and departments involved in planning integrated services. Furthermore, given the variety of locations where women may present and the range and potential severity of presenting health problems, there is an urgent need for coherent, effective referral within the health sector, and the need for strong local partnership to facilitate effective referral to external, non-health services.

Intimate partner violence and its implication for pregnancy

Intimate partner violence (IPV) is a common occurrence in pregnancy and results in an increased risk of adverse outcomes. Homicide may be the most common cause of maternal death. Women who are pregnant and the victims of IPV have high rates of stress, are more likely to smoke or use other drugs, deliver a preterm or low birth weight infant, have an increase in infectious complications, and are less likely to obtain prenatal care. The IPV continues in the postpartum period. Adolescents may be at even higher risk than their adult counterparts. Children raised in violent homes have both immediate and life long adverse health outcomes as a result of their exposure to IPV. IPV adds substantially to healthcare costs both for direct services to treat the injuries and higher utilization of a wide range of healthcare services. Healthcare providers, particularly those who care for pregnant women, are in a unique position to identify these women and direct them and their families to the help they need to end the violence in their lives.

Psychosocial correlates of depression symptoms during the third trimester of pregnancy

OBJECTIVE

To explore the psychosocial correlates of depression symptoms during the third trimester of pregnancy.

DESIGN

Cross-sectional design guided by Selye's theory of stress.

SETTING

Prenatal care provider offices or mutually agreeable locations in the Pacific Northwest.

PARTICIPANTS

One hundred thirty-nine women in their third trimester of pregnancy. The majority was Caucasian and married. Fifty-two of the participants (38%) had scores greater than or equal to 16 on the Centers for Epidemiologic Studies Depressed Mood Scale.

MAIN OUTCOME MEASURE

The Centers for Epidemiologic Studies Depressed Mood Scale.

RESULTS

Stepwise linear regression indicated that 46% of the variance of third-trimester depressive symptoms was due to brief and intermittent negative mood states that occurred primarily during the first trimester, a lack of marital satisfaction and social support, and gravida. Lifetime abuse did not contribute significantly to third-trimester depression symptoms.

CONCLUSIONS

One third of the sample reported subclinical levels of depression symptoms. Prenatal care providers may want to consider these minor and brief mood changes as predictive of depression symptoms later in pregnancy, particularly when experienced during the first trimester.

Intimate partner violence during pregnancy: incidence and associated health behaviors in a rural population

OBJECTIVES

The goal of this investigation was to examine the prevalence of different types of intimate partner violence (IPV) during pregnancy, as well as the association between both physical and psychological IPV and negative health behaviors, including smoking, other substance use, inadequate prenatal care utilization, and nutrition, in a rural sample.

METHODS

104 southern Appalachian women, primarily Caucasian and lower SES, completed a pregnancy interview focused on IPV (CTS2) and health behaviors. Medical records were also reviewed.

RESULTS

81% of participants reported some type of IPV during the current pregnancy, with 28% reporting physical IPV, and 20% reporting sexual violence. More than half were current smokers. Physical IPV during pregnancy was associated with significantly increased rates of pregnancy smoking (including decreased rates of quitting and reducing), increased rates of alcohol, marijuana, and harder illicit drug use around the time of conception, and later entry into prenatal care. The experience of psychological IPV during pregnancy was associated with a significantly decreased likelihood of quitting or reducing smoking during pregnancy, an increased rate of alcohol use around the time of conception, and an increased rate of pre-pregnancy obesity.

CONCLUSIONS

In this sample, pregnancy IPV and smoking occurred at rates well above national averages. Additionally, while physical IPV during pregnancy was associated with several negative pregnancy health behaviors, the experience of psychological IPV, even in the absence of physical IPV, also placed women at increased risk for negative health behaviors, all of which have been linked to poor pregnancy and newborn outcomes.

Abuse during pregnancy: current theory and new contextual understandings

This study used Landenburger's theory, a process of leaving and recovering from an abusive relationship, as a framework to interview 35 pregnant women identified as being at high risk for abuse. Results are reported on 18 women who disclosed active abuse during the study. Landenburger's model was not a good fit. Our participants became trapped and endured violent relationships if they perceived this was the best situation for their unborn child. Additionally the chaos, instability, and lack of resources experienced by these women likely contributed to their inability to complete the four phases described by Landenburger's model for non-pregnant women.

Nurse case management for pregnant women experiencing or at risk for abuse

OBJECTIVE

To determine whether individualized nursing case management can decrease stress among pregnant women at risk for or in abusive relationships.

DESIGN

A multisite randomized controlled trial.

SETTING

Two prenatal clinics in the Pacific Northwest and rural Midwest.

PARTICIPANTS

1,000 women who spoke English and were 13 to 23 weeks pregnant at time of recruitment.

INTERVENTION

All intervention group women (N = 499) were offered an abuse video and had access to a nurse case manager 24/7. Additionally, participants at risk for or in abusive relationships received individualized nursing care management throughout the pregnancy.

RESULTS

The most frequent nursing care management activities were providing support (38%) and assessing needs (32%). The nursing care management group received an average of 22 contacts, most (80%) by telephone and had a significant reduction in stress scores as measured by the Prenatal Psychosocial Profile. Compared to the control group, the differences were in the predicted direction, but not statistically different. A major finding was the choice by abused women to focus on basic needs and their pregnancies rather than the abuse, although all received safety planning.

CONCLUSIONS

Pregnant women at risk for or in abusive relationships experience very stressful and complex lives. Nurses need to focus on the needs they identify, which may not be the abusive relationship.

Domestic violence during pregnancy: implications for practice

Domestic violence affects many women and their families. Although estimates of the prevalence of domestic violence during pregnancy vary, it is likely that most providers of women's health care will encounter pregnant women who experience domestic violence. The purpose of this article is to review research that has investigated associations between domestic violence during pregnancy and other demographic and lifestyle variables, as well as the literature regarding clinical assessment and intervention strategies.