An integrated intervention to reduce intimate partner violence in pregnancy: a randomized controlled trial

The Associations Between Intimate Partner Violence and Mental Health Outcomes Among Sexual Minority Men: A Systematic Review and Meta-Analysis

Sexual minority men (SMM) experience intimate partner violence (IPV) at a substantially high rate and also bear high burdens of adverse mental health outcomes. This systematic review and meta-analysis aimed to consolidate existing evidence on the associations between experiencing IPV and adverse mental health outcomes (depressive symptoms, anxiety, stress, etc.) among SMM. Following the Preferred Reporting Items For Systematic Reviews and Meta-Analyses guideline, we identified 22 published studies encompassing data from 18,454 individuals, all of which were cross-sectional in design and half of which were conducted in the U.S. We found that experiencing IPV was associated with an increased risk of depressive symptoms and anxiety with a pooled Adjusted Odds Ratios (AORs) of 1.71 (95% CI [1.43, 2.05]) and 1.89 (95% CI [1.46, 2.43]), respective. Studies also found that IPV was positively associated with suicide-related risk (AOR = 2.71, 95% CI [2.21, 3.32] and perceived loneliness. Studies varied in their IPV measures and recall periods and used diverse mental health measurement tools like PHQ-9/GAD-7, Perceived Stress Scale, and the Suicide Behaviors Questionnaire-Revised. This systematic review and meta-analysis revealed an urgent need to examine the effects of IPV on SMM's mental well-being in low- and middle-income countries using standardized IPV measurement tools. Future research should employ a longitudinal design to track the long-term effects of IPV on the mental well-being of SMM and explore potential interventions for mitigating these impacts over time. These insights are crucial for enhancing IPV screening within healthcare settings and identifying key intervention targets aimed at improving the mental health of SMM.

Prevalence and Correlates of Intimate Partner Violence Among Women and Men in Mexico: A Systematic Review and Meta-analysis

This article presents the first systematic review and meta-analysis of the prevalence and correlates of different forms of intimate partner violence (IPV) among women and men in Mexico. To identify studies, a comprehensive search strategy was developed and executed across 11 databases (Academic Search Complete, APA PsycInfo, CINAHL, Cochrane CENTRAL, Embase, International Bibliography of the Social Sciences, LILACS, MEDLINE, SciELO, Sociological Abstracts, Web of Science). From the 1,746 studies screened, 155 full-text articles were reviewed, and this systematic review included 27 studies involving 249,557 participants to determine the prevalence of physical, psychological, sexual, threats, and other forms of IPV, according to gender and other sociodemographic characteristics. Overall IPV prevalence was 16.4%, with significant differences across pregnant and non-pregnant women. Physical IPV prevalence was 14.7%, revealing higher rates in men (29.5%) compared to women (14.2%). Psychological IPV prevalence was 27.3% and sexual IPV was at 6.6%, with differences across evaluation periods. Threats and other IPV forms showed a prevalence rate of 14.2% and 21.5%. Meta-regression analyses included gender, education, marital status, rural residency, pregnancy, age, and evaluation period. This study demonstrates that IPV is a critical public health concern in Mexico, impacting both women and men. It shows the vulnerability of rural residents, youth, and pregnant women. However, understanding IPV complexities in Mexico requires nuanced considerations of demographic and situational contexts. Urgent initiatives from municipal, state, and federal governments are needed to combat IPV, focusing on prevention and support for affected individuals.

Intimate partner violence during pregnancy: To screen or not to screen?

Intimate partner violence (IPV) during pregnancy emerges as a compelling and urgent concern within the domain of public health, casting a long shadow over a substantial cohort of women. Its pernicious consequences extend beyond the individual, enveloping the well-being of both the mother and the fetus, giving rise to an elevated risk of preterm birth, low birth weight, fetal harm, and maternal psychological distress, including depression, anxiety, post-traumatic stress disorder, and, tragically, maternal mortality. Despite the prevalence of IPV being comparable to other conditions like gestational diabetes and preeclampsia, a universal screening protocol for IPV remains absent globally. We reviewed the clinical guidelines and practices concerning IPV screening, painstakingly scrutinizing their contextual nuances across diverse nations. Our study unveils multifaceted challenges of implementing universal screening. These hurdles encompass impediments to victim awareness and disclosure, limitations in healthcare providers' knowledge and training, and the formidable structural barriers entrenched within healthcare systems. Concurrently, we delve into the potential biomarkers intricately entwined with IPV. These promising markers encompass inflammatory indicators, epigenetic and genetic influences, and a diverse array of chemical compounds and proteins. Lastly, we discussed various criteria for universal screening including (1) valid and reliable screening tool; (2) target population as pregnant women; (3) scientific evidence of screening programme; and (4) integration of education, testing, clinical services, and programme management to minimise the challenges, which are paramount. With the advancement of digital technology and various biomarkers identification, screening and detecting IPV in clinical settings can be conducted systemically. A systems-level interventions with academia-community-indutrial partnerships can help connect pregnant women to desire support services to avoid adverse maternal and child health outcomes.

Interventions for intimate partner violence during the perinatal period: A scoping review: A systematic review

Background

Intimate partner violence (IPV) is a prevalent global health problem. IPV that occurs before pregnancy often continues during the perinatal period, resulting in ongoing violence and many adverse maternal, obstetrical, and neonatal outcomes.

Objectives

This scoping review is designed to broadly capture all potential interventions for perinatal IPV and describe their core components and measured outcomes.

Search Methods

We conducted a search for empirical studies describing IPV interventions in the perinatal population in June 2022. The search was conducted in MEDLINE, EMBASE, PsycInfo, CINAHL, Cochrane Central Register of Controlled Trials, Web of Science, Applied Social Sciences Index & Abstracts, ClinicalTrials.gov and MedRxiv. Hand searching of references from select articles was also performed.

Selection Criteria

Included studies described an intervention for those experiencing IPV during the perinatal period, including 12 months before pregnancy, while pregnant or in the 12 months post-partum. The search encompassed January 2000 to June 2022 and only peer-reviewed studies written in either English or French were included. Included interventions focused on the survivor exposed to IPV, rather than healthcare professionals administering the intervention. Interventions designed to reduce IPV revictimization or any adverse maternal, obstetrical, or neonatal health outcomes as well as social outcomes related to IPV victimization were included.

Data Collections and Analysis

We used standard methodological procedures expected by The Campbell Collaboration.

Main Results

In total, 10,079 titles and abstracts were screened and 226 proceeded to full text screening. A total of 67 studies included perinatal IPV interventions and were included in the final sample. These studies included a total of 27,327 participants. Included studies originated from 19 countries, and the majority were randomized controlled trials (n = 43). Most studies were of moderate or low quality. Interventions included home visitation, educational modules, counseling, and cash transfer programs and occurred primarily in community obstetrician and gynecologist clinics, hospitals, or in participants' homes. Most interventions focused on reducing revictimization of IPV (n = 38), improving survivor knowledge or acceptance of violence, knowledge of community resources, and actions to reduce violence (n = 28), and improving maternal mental health outcomes (n = 26). Few studies evaluated the effect of perinatal IPV interventions on obstetrical, neonatal or child health outcomes.

Authors' Conclusions

The majority of intervention studies for perinatal IPV focus on reducing revictimization and improving mental health outcomes, very few included obstetrical, neonatal, and other physical health outcomes. Future interventions should place a larger emphasis on targeting maternal and neonatal outcomes to have the largest possible impact on the lives and families of IPV survivors and their infants.

The effect of a behavioural intervention package on quality of life of pregnant women experiencing domestic violence: a randomised controlled trial

BACKGROUND

Domestic violence during pregnancy is especially concerning due to its significant detrimental impact on a woman's health and that of her unborn child. The study aims to evaluate the effects of a behavioural intervention package (BIP) delivered during pregnancy on the quality of life (QOL), domestic violence (DV), and reproductive and child health (RCH) of women experiencing DV.

METHODS

A randomised controlled trial was conducted on 211 pregnant women recruited between 18 and 20 weeks of pregnancy and randomly assigned to one of two groups: intervention (n = 105) or control (n = 106). The intervention group received BIP and standard care, while the control group received only standard care for 28 weeks. Study tools included socio-demographic variables, a short-form health survey, an abuse assessment screening tool, and an RCH checklist. The tools were completed once before the intervention and again at 6 weeks postnatal. The tools and their subscales were compared pre- and post-intervention using a paired t-test, or Wilcoxon signed test as appropriate to estimate the effect size at baseline and post-intervention.

RESULTS

Post-intervention, the QOL scores were found to be significant, with a positive effect favouring the intervention as compared to the control group. The BIP intervention, which was found to be significantly effective (P ≤ 0.001) in reducing DV for pregnant women experiencing DV, was higher in the intervention group than in the control group.

CONCLUSION

The BIP may be an appropriate method for treating pregnant women experiencing DV from low socioeconomic strata who attend public hospitals in India to improve their QOL. The approach may offer an intervention that healthcare institutions or other organizations in contact with women at risk of violence can implement.

TRIAL REGISTRATION

Indian Registry of Clinical Trials CTRI/2019/01/017009. Registered on 09/01/2019.

Integrated domestic violence and reproductive health interventions in India: a systematic review

BACKGROUND

Domestic violence is a leading cause of poor health outcomes during pregnancy and the postpartum period. Therefore, there is a need for integrated domestic violence interventions in reproductive health care settings. India has one of the highest maternal and child mortality rates. This review aimed to identify characteristics of existing evidence-based integrated domestic violence and reproductive healthcare interventions in India to identify gaps and components of interventions that demonstrate effectiveness for addressing domestic violence.

METHODS

A systematic review of intervention studies was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Three research team members performed independent screening of title, abstracts and full-texts.

RESULTS

The search resulted in 633 articles, of which 13 articles met inclusion criteria for full text screening and analysis. Common components of integrated violence and reproductive health interventions that were effective in addressing domestic violence included: psychoeducation/education (n = 5), skill building (n = 5), counseling (n = 5), engaging stakeholders with use of trained lay peer facilitators (n = 3), and engaging male spouses (n = 3).

CONCLUSIONS

Interventions in India for domestic violence that are integrated with reproductive health care remain few, and there are fewer with effective outcomes for domestic violence. Of those with effective outcomes, all of the interventions utilized psychoeducation/education, skill building, and counseling as part of the intervention.

The Impact of Social Determinants of Maternal Mental Health in Marginalized Mothers

Background: A deeper understanding of the key determinants of maternal mental health is important for improving care for women, especially women who are at an economic disadvantage. Objectives: To explore the associations of select social determinants: access, social support, and stress, with the onset of antepartum depression in low-income mothers. Participants: The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing, population-based surveillance system with selected data from 2016 to 2019, establishing a randomly selected sample of women with a recent live birth at most 4 months postdelivery, between 1,300 and 3,400 women per state (n ∼ 162,558). Methods: In this cross-sectional study, the phase 8 PRAMS was adapted to measure social support, access, stress, and their relationships with the onset of antepartum depression in low-income mothers. To assess low-income marginalization, a threshold was established based on income levels within 130% of the federal poverty level; antepartum (n ∼ 41,289). Results: The defined access, social support, and stress factors showed a statistically significant association with the onset of antepartum depression among low-income mothers. Of women in this sample, 22.6% indicated antepartum depression (p < 0.001; R2 = 0.066). Negative social support indicators were associated with an increased likelihood of antepartum depression; 3.71 increased odds of depression for abuse during pregnancy, and 0.79 decreased odds with positive acknowledgment of paternity. Access indicator terms showed an association with the decreased likelihood of antepartum depression through breastfeeding information support (Info from Baby Doc, odds ratio [OR] = 0.86), prenatal care utilization (12+ visits, OR = 0.82), and specific insurance type (insurance by job, OR = 0.82). All instances of stressful life events showed an increased likelihood of depression during pregnancy (for majority of stressful life events: OR >1.12). Conclusions: Economically marginalized mothers face unmet social and health care needs leading to poorer outcomes during pregnancy. These findings provide additional support for improved policy and public health efforts, such as assessment, education, and interventions, to decrease prevalence and improve treatment for antepartum depression among marginalized mothers.

Examining the Relationship between Social Determinants of Health and Adverse Pregnancy Outcomes in Black Women

OBJECTIVE

Our objective was to examine associations between social determinants of health (cultural, neighborhood, and psychosocial factors) and adverse pregnancy outcomes (gestational age at birth [GAB], preterm birth [PTB], and preeclampsia) in Black women.

STUDY DESIGN

Cross-sectional data (n = 204) comprised adult Black women aged ≥18 years who delivered between 2013 and 2022 in Milwaukee,Wisconsin. Sequential unadjusted linear and logistic regression models were run to evaluate associations between social determinants of health and pregnancy outcomes. Stepwise regressions with forward selection were run to test the contribution of the social determinants of health to adverse pregnancy outcomes, independent of the contribution of established risk factors.

RESULTS

Mean GAB was 37.9 weeks, 19.6% had a PTB and 17.7% had preeclampsia. In all fully adjusted models, education (β0.15, 95% confidence interval [CI]: 0.005, 0.29), nulliparity (β -1.26, 95%CI: -2.08, -0.44), multifetal gestation (β -2.67, 95% CI: -4.29, -1.05), and exposure to neighborhood violence (β -0.13, 95%CI: -0.25, -0.005) were associated with shortened GAB. Education (adjusted odds ratio [aOR]: 0.83, 95%CI: 0.69, 0.99), provider trust (aOR: 0.94, 95%CI: 0.88, 0.99), chance health locus of control (aOR: 0.88, 95%CI: 0.78, 0.99), and anxiety (aOR: 0.81, 95%CI: 0.69, 0.95) were associated with reduced odds of PTB. Powerful others health locus of control (aOR: 1.16, 95%CI: 1.03, 1.32), depression (aOR: 1.17, 95%CI: 1.01, 1.34), nulliparity (aOR: 4.73, 95%CI: 1.79, 12.55), multifetal gestation (aOR: 17.78, 95%CI: 3.49, 90.50), diabetes (aOR: 4.71, 95%CI: 1.17, 19.00), and obstructive sleep apnea (aOR: 44.28, 95%CI: 2.50, 783.12) were associated with increased odds of PTB. Internal health locus of control (aOR: 1.13, 95%CI: 1.01, 1.25), depression (aOR: 1.09, 95%CI: 1.01, 1.17), preeclampsia in a previous pregnancy (aOR: 5.96, 95% CI: 2.22, 16.01), and kidney disease (aOR: 34.27, 95% CI: 1.54, 763.75) were associated with preeclampsia.

CONCLUSION

Provider trust, health locus of control, neighborhood violence, depression, and anxiety were associated with adverse pregnancy outcomes in Black women, independent of demographic and clinical risk factors.

KEY POINTS

· We identified associations between exposure to neighborhood violence and gestational age at birth.. · Trust, locus of control, depression, and anxiety were associated with preterm birth and preeclampsia.. · Future research should focus on interventions that address social and clinical factors..

Interventions to Prevent Intimate Partner Violence: A Systematic Review and Meta-Analysis

Intimate partner violence (IPV) remains a global health and human rights problem. This systematic review assesses the effects of preventive interventions on the occurrence of IPV experience or perpetration. Twenty-six studies published between January 1, 2008 and March 31, 2022 were included, contributing 91 effect sizes. Multilevel meta-analysis showed a protective pooled effect (risk ratio = 0.85, 95% CI [0.77, 0.99]). Interventions (also) including men were more effective than interventions for women only. No other moderators were found. Findings underscore that various IPV prevention interventions are now available that can improve the health and rights of women in diverse settings.

Assessing the Nepalese health system's readiness to manage gender-based violence and deliver psychosocial counselling

Violence against women (VAW), particularly intimate partner violence (IPV) or domestic violence, is a major public health issue, garnering more attention globally post-coronavirus disease 2019 (COVID-19) lockdown. Health providers often represent the first point of contact for IPV victims. Thus, health systems and health providers must be equipped to address survivors' physical, sexual and mental health care needs. However, there is a notable lack of evidence regarding such readiness in Nepal. This study, utilizing a concurrent triangulation design, evaluated the readiness of public health facilities in Nepal's Madhesh Province in managing VAW, focusing on providers' motivation to offer psychosocial counselling to survivors. A cross-sectional study was conducted across 11 hospitals and 17 primary health care centres, where 46 health care providers were interviewed in February-April 2022. The study employed the World Health Organization's tools for policy readiness and the Physician Readiness to Manage IPV Survey for data collection. Quantitative and qualitative data were collected via face-to-face interviews and analysed using descriptive and content analysis, respectively. Only around 28% of health facilities had trained their staff in the management of VAW. Two out of 11 hospitals had a psychiatrist, and a psychosocial counsellor was available in four hospitals and two out of 17 primary health care centres. Two-thirds of all health facilities had designated rooms for physical examinations, but only a minority had separate rooms for counselling. Though a few health facilities had guidelines for violence management, the implementation of these guidelines and the referral networks were notably weak. Hospitals with one-stop crisis management centres demonstrated readiness in VAW management. Health providers acknowledged the burden of IPV or domestic violence and expressed motivation to deliver psychosocial counselling, but many had limited knowledge. This barrier can only be resolved through appropriate training and investment in violence management skills at all tiers of the health system.

The prevalence of intimate partner violence among Iranian pregnant women: a systematic review and meta-analysis

BACKGROUND

Intimate partner violence against pregnant women is an important public health concern and human rights issue. According to the various findings of previous studies, this study was conducted to assess the pooled prevalence of intimate partner violence against Iranian women.

METHODS

In this systematic review and meta-analysis, a literature search was conducted in databases such as PubMed, Scopus, Web of Science, MagIran, and Scientific Information Database without a time limit. Heterogeneity was assessed by Cochrane Q test statistics and the I2 test, and the results were incorporated into a random effects model to estimate the prevalence of intimate partner violence. Data analysis was performed using R software version 4.3.2.

RESULTS

The overall prevalence of intimate partner violence was reported to be 51.5% (95% confidence interval (CI) 45.0-58.1), and the prevalence rate of physical, sexual, and psychological intimate partner violence was 18.0% (95% CI 15.1-20.9), 22.1% (95% CI 17.7-26.60) and 43.2% (95% CI 36.6-49.8), respectively. The lowest level of physical, sexual, and emotional intimate partner violence rate was observed in district 1 of Iran (includes Tehran, the capital of Iran and the surrounding provinces). The rate of physical and sexual intimate partner violence prevalence decreased with the increased mean age of the husband (P=0.005) and the mean age of the wife (P=0.035), respectively.

CONCLUSIONS

Studies included in this review report that more than half of Iranian women experience violence during pregnancy. In order to prevent adverse maternal and neonatal consequences, it is necessary to identify these women and introduce them to support centres.

Feasibility and Effectiveness of an Intervention to Reduce Intimate Partner Violence and Psychological Distress Among Women in Nepal: Protocol for the Domestic Violence Intervention (DeVI) Cluster-Randomized Trial

BACKGROUND

Intimate partner violence (IPV) disproportionately affects people in low-and middle-income countries (LMICs), such as Nepal. Women experiencing IPV are at higher risk of developing depression, anxiety, and posttraumatic stress disorder. The shortage of trained frontline health care providers, coupled with stigma related to IPV and mental health disorders, fuels low service uptake among women experiencing IPV. The Domestic Violence Intervention (DeVI) combines the Problem Management Plus counseling program developed by the World Health Organization with a violence prevention component.

OBJECTIVE

This study aims to implement and evaluate the feasibility, acceptability, and effectiveness of DeVI in addressing psychological distress and enabling the secondary prevention of violence for women experiencing IPV.

METHODS

A parallel cluster-randomized trial will be conducted across 8 districts in Madhesh Province in Nepal, involving 24 health care facilities. The study will include women aged 18-49 years who are either nonpregnant or in their first trimester, have experienced IPV within the past 12 months, have a 12-item General Health Questionnaire (GHQ-12) score of 3 or more (indicating current mental health issues), and have lived with their husbands or in-laws for at least 6 months. A total sample size of 912 was estimated at 80% power and α<.05 statistical significance level to detect a 15% absolute risk reduction in the IPV frequency and a 50% reduction in the GHQ-12 score in the intervention arm. The health care facilities will be randomly assigned to either the intervention or the control arm in a 1:1 ratio. Women visiting the health care facilities in the intervention and control arms will be recruited into the respective arms. In total, 38 participants from each health care facility will be included in the trial to meet the desired sample size. Eligible participants allocated to either arm will be assessed at baseline and follow-up visits after 6, 17, and 52 weeks after baseline.

RESULTS

This study received funding in 2019. As of December 29, 2022, over 50% of eligible women had been recruited from both intervention and control sites. In total, 269 eligible women have been enrolled in the intervention arm and 309 eligible women in the control arm. The trial is currently in the recruitment phase. Data collection is expected to be completed by December 2023, after which data analysis will begin.

CONCLUSIONS

If the intervention proves effective, it will provide evidence of how nonspecialist mental health care providers can address the harmful effects of IPV in resource-constrained settings with a high burden of IPV, such as Nepal. The study findings could also contribute evidence for integrating similar services into routine health programs in LMICs to prevent IPV and manage mental health problems among women experiencing IPV.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05426863; https://clinicaltrials.gov/ct2/show/NCT05426863.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45917.

Pathways to adverse pregnancy outcomes: exploring the mediating role of intimate partner violence and depression: results from a South African rape cohort study

Adverse pregnancy outcomes (APOs) are common occurrences that contribute to negative maternal and child health outcomes. Our aim was to test the hypothesis that trauma exposure and depression are drivers of the better-recognised risk factors for miscarriage, abortion and stillbirths. Our comparative cohort study based in Durban, South Africa recruited women who reported a recent rape (n = 852) and those who had never experienced rape (n = 853), with follow-up for 36 months. We explored APOs (miscarriage, abortion or stillbirth) among those having a pregnancy during follow-up (n = 453). Potential mediators were baseline depression, post-traumatic stress symptoms, substance abuse, HbA1C, BMI, hypertension and smoking. A structural equation model (SEM) was used to determine direct and indirect paths to APO. Overall, 26.6% of the women had a pregnancy in the follow-up period and 29.4% ended in an APO, with miscarriage (19.9%) the most common outcome, followed by abortion (6.6%) and stillbirths (2.9%). The SEM showed two direct pathways from exposure to childhood trauma, rape and other trauma, to APO which were ultimately mediated by hypertension and/or BMI, but all paths to BMI were mediated by depression and IPV-mediated pathways from childhood and other trauma to hypertension. Food insecurity mediated a pathway from experiences of trauma in childhood to depression. Our study confirms the important role of trauma exposure, including rape, and depression on APOs, through their impact on hypertension and BMI. It is critical that violence against women and mental health are more systematically addressed in antenatal, pregnancy and postnatal care.

Evaluating the Effectiveness of a Psychological and Adventure-based Multicomponent Therapeutic Program for Victims of Intimate Partner Violence: A Pilot Study

Intimate partner violence (IPV) is a global health problem with different negative consequences for women's mental health. This pilot study aims to evaluate the efficacy of a multicomponent intervention for battered women using a comparison group design to analyze improvement in self-esteem, self-concept, self-efficacy, body dissatisfaction, and depression. The intervention consisted of an eight-session multicomponent intervention program based on the combination of group psychological therapy and adventure activities. The study sample originally consisted of 34 women IPV victims. Self-report psychological assessment was conducted during the pre-test and post-test while interviews were conducted during the post-test among the experimental group. The results of this pilot study suggest the efficacy of the cognitive-behavioral multicomponent intervention on self-esteem, self-efficacy, and depression in the IPV victims from the experimental group. We conclude that these findings support the efficacy of this psychological intervention program. Practical implications and suggestions are also discussed.

Intimate partner violence among pregnant women attending prenatal care in Bondo sub-county, Western Kenya

OBJECTIVES

To investigate prevalence and factors that contribute to intimate partner violence among pregnant women attending prenatal care in Bondo sub-county, Western Kenya.

METHODS

This cross-sectional analysis was conducted in three health facilities in Bondo, Western Kenya, from August 2020 to August 2021. Using systematic sampling 360 pregnant women attending prenatal care were selected. Structured questionnaires were used to collect data. Risk factors for intimate partner violence were determined using logistic regression.

RESULTS

Out of the 360 respondents, 127 (35.3%) faced intimate partner violence during pregnancy. Among these, 86 (23.9%) experienced psychological violence, 56 (15.6%) experienced physical abuse, and 59 (16.4%) experienced sexual violence. Unemployment (adjusted odds ratio [aOR] 2.90; 95% confidence intervals [CI] 1.08-7.79), the inability to count on parents or siblings for support (aOR 2.48; 95% CI 1.14-5.43), and having a partner that drinks alcohol either daily (aOR 4.84; 95% CI 1.69-13.88) or occasionally (aOR 2.19; 95% CI 1.16-4.13) were independently associated with intimate partner violence during pregnancy.

CONCLUSION

In this setting, intimate partner violence prevalence among pregnant women was high. Unemployment, having an alcohol-drinking partner, and the inability to count on parents or siblings for support were contributing factors.

Intimate partner violence and HIV treatment adherence in urban South Africa: Mediating role of perinatal common mental disorders

Background

Antiretroviral therapy (ART) has potential to eliminate perinatal HIV infections, but adherence to ART in late pregnancy and postpartum is often suboptimal. Intimate partner violence (IPV) may influence non-adherence among perinatal women living with HIV (WWH), but few quantitative studies have examined this over time or explored mechanisms for this association.

Methods

We used secondary data from a parent trial in Johannesburg comprising WWH from the control arm (n=63) and WWH ineligible for the trial (n=133). Trained nurse researchers administered questionnaires at first antenatal visit on past-year psychological, physical, and/or sexual IPV (WHO instrument), socio-demographics (age, food security, education), and perinatal common mental symptoms of depression (Hospital Anxiety and Depression Screener-d); anxiety (HADS-a); post-traumatic stress disorder (PTSD; Harvard Trauma Questionnaire). At endline visit 2-4 months postpartum, nurse researchers assessed self-reported ART adherence using a visual analog scale (with ≥95% considered "good"). We fitted structural equation models (SEM) in MPlus to explore direct and indirect effects of IPV on ART adherence.

Results

Of 196 perinatal WWH, 53.1% reported IPV exposure at baseline. The majority of participants (85.7%) had good perinatal ART adherence. In adjusted models, IPV at baseline was associated with halved odds of good adherence (aOR=0.51, 95%CI=0.20-0.96). IPV was associated with higher adjusted odds of probable depression (aOR=4.64), anxiety (aOR=2.85), and PTSD (aOR=3.42). In SEM, IPV had a direct (standardized coef=-0.22) and indirect effect (coef=-0.05) on ART via common mental disorders. The total effect of IPV on perinatal adherence was of moderate size (coef= -0.27) and the model had good fit (CFI=0.972; TLI=0.969; RMSEA=0.045; SRMR=0.076).

Conclusion

IPV was longitudinally associated with perinatal ART non-adherence in part due to its relationship with mental health symptomology. Addressing IPV within clinical care has potential to improve perinatal mental health, maternal HIV outcomes, and HIV-free infant survival.

Safety Planning With Marginalized Survivors of Intimate Partner Violence: Challenges of Conducting Safety Planning Intervention Research With Marginalized Women

Intimate partner violence (IPV) disproportionately affects marginalized women in the United States. This calls for effective safety planning strategies to reduce the risk for future revictimization and address safety needs of survivors from marginalized groups. This review identified types of interventions that incorporated safety planning and were successful in reducing the risk for future revictimization among IPV survivors from diverse groups, examined elements of safety planning in effective interventions, and described challenges or limitations in safety planning intervention research with marginalized women. A systematic search of five databases was performed. The search resulted in inclusion of 17 studies for synthesis. The included studies were quantitative, U.S.-based, evaluated interventions with a safety planning component, and had an outcome of change in IPV. Effective interventions that incorporated safety planning were empowerment and advocacy focused. Elements included were comprehensive assessments of survivors' unique needs and situations, educating them about IPV, helping them identify threats to safety, developing a concrete safety plan, facilitating linkage with resources, providing advocacy services as needed, and conducting periodic safety check-ins. For survivors with mental and behavioral health issues, effective interventions included psychotherapeutic approaches along with safety planning to address survivors' co-occurring health care needs. Although most studies reported positive findings, there were limitations related to designs, methods, adequate inclusion, and representation of marginalized women and cultural considerations. This calls for additional research using rigorous and culturally informed approaches to establish an evidence base for effective interventions that specifically address the safety planning needs of marginalized survivors of IPV.

Pregnancy complications and intimate partner violence: The moderating role of prenatal posttraumatic stress symptoms

Intimate partner violence (IPV) and posttraumatic stress disorder increase the risk of poor pregnancy outcomes, but associations among IPV exposure, mental health, and pregnancy complications remain underexplored. This study assessed the interaction between three types of IPV exposure (i.e., physical, sexual, psychological) and posttraumatic stress symptoms (PTSS) on prenatal complications (e.g., preeclampsia, gestational diabetes) among pregnant women exposed to IPV. Participants included 137 IPV-exposed pregnant women (M_age = 27.29, SD = 6.00; 66.9% African American/Black). Three regression models were run to test the main effect of each type of IPV and PTSS on pregnancy complications, and the moderating effect of PTSS on the association between IPV and pregnancy complications, controlling for socioeconomic status, gestational age, and childhood trauma. Main effects were observed for sexual coercion, β = .32, p = .010, R² _part = .050, and PTSS, β = 0.19, p = .039, R² _part = .026, with more frequent sexual IPV and higher levels of PTSS associated with more pregnancy complications. Moderating effects were also evident, with the IPV x PTSS interaction significant for all three IPV domains: psychological aggression, f² = .046; sexual coercion, f² = .079; and physical assault, f² = .048. PTSS strengthened the positive association between psychological and sexual IPV and pregnancy complications. Physical IPV and pregnancy complications were inversely related for participants with low-level PTSS. Results provide novel information on how IPV types and PTSS function together during pregnancy. Findings highlight the need for evidence-based prenatal interventions that successfully address both IPV exposure and PTSS severity.

Organization-Based Factors Bearing on Provider Screening and Referral Practices for Women Exposed to Intimate Partner Violence

Essential steps in the provision of health care for women exposed to intimate partner violence (IPV) are screening and referral for specialized services, as might occur in primary care settings. Prior to participating in a cross-disciplinary IPV training program, medical care (N = 223) and social/behavioral practitioners (N = 197) completed a survey that ascertained current practices, provisions, and perceived barriers related to IPV screening and referral. Roughly half of the study participants did not routinely screen their patients/clients for IPV, with no differences for the professional groupings. Utilization of referral resources was significantly lower for medical care providers, 78.5% of whom did not use any. Perceived barriers to screening and referral were examined as practitioner-based and organization-based, and we identified tangible provisions (protocols and practice materials) as a relevant variable. As we conjectured, organization-based barriers were more strongly associated with lower rates of screening and referral than were practitioner-based barriers, regardless of professional grouping. Moreover, tangible provisions, controlling for perceived barriers, significantly added to routine screening and frequency of referral resources usage, particularly for medical care providers. Results are discussed in the context of a systems-level approach to improving IPV services in health care with organizational practice enhancements.

MOSAIC (MOthers’ AdvocateS In the Community) for pregnant women and mothers of children under 5 with experience of intimate partner violence: A pilot randomized trial study protocol

Background

Pregnancy and motherhood increase the risk for long-term exposure to physical, psychological and sexual intimate partner violence (IPV; sexual or physical violence by current or former partners). Pregnant women and mothers with children under 5 who have experienced IPV exhibit poor physical and mental health and obstetric outcomes. Depression and posttraumatic stress disorder (PTSD) are the two most common mental health consequences of IPV. There is good evidence that women with good social support have better mental health and IPV outcomes.

Methods

This study will develop MOthers’ AdvocateS In the Community (MOSAIC) Plus intervention for pregnant women and mothers with children under the age of 5. MOSAIC uses trained mentor mothers and has been found to reduce subsequent IPV. This study will blend the original MOSAIC intervention with principles of interpersonal psychotherapy (IPT) to address symptoms of depression, PTSD, and prevent subsequent risk of IPV. We will conduct a pilot randomized trial of the MOSAIC Plus intervention compared to the traditional MOSAIC intervention to determine its feasibility and acceptability. Study samples include focus groups (n = 36), open trial (n = 15), and a randomized pilot trial including 40 pregnant women and mothers with children under 5 who report current/recent of IPV and elevated symptoms of maternal depression and/or PTSD. The study’s primary outcome will be changes in maternal depressive and PTSD symptoms. Secondary outcomes will include reduction in subsequent IPV, improvement in functioning, changes in social support and effectiveness in obtaining resources.

Discussion

This is a formative study evaluating the feasibility and acceptability of a mentor mother intervention for pregnant women and mothers with children under 5. Promising results of this study will be used for a larger, fully-powered randomized trial evaluating the effectiveness of a mentor mother intervention in preventing subsequent IPV and reducing depressive and PTSD symptoms in this population.

The magnitude and determinants of depressive symptoms amongst women in early pregnancy in Southern Nigeria: A cross-sectional study

Background

Antenatal depression (AD) is prevalent and associated with adverse pregnancy, maternal and child outcomes, yet no study has addressed its magnitude and predictors in early pregnancy in Nigeria.

Aim

To determine the prevalence and factors associated with AD in first half of pregnancy.

Setting

Multicentric health facilities in Southern Nigeria.

Methods

A multicentric health-facilities-based cross-sectional study was conducted from January to July 2018. Using pretested structure interviewer-administered questionnaires, antenatal depressive symptoms were assessed amongst 511 pregnant mothers with the Edinburg Postnatal Depressive Scale tool. Socio-demographic, socio-economic, clinical, family and social factors were also measured. Descriptive statistics, bivariate and multivariable logistic regression analyses were employed to describe and identify factors associated with AD.

Results

The prevalence of antenatal depressive symptoms in early pregnancy in this study was 29.4% (95% confidence interval [CI] 26.6–32.9). Factors independently associated with AD were intimate partner violence (adjusted odds ratios [AOR] = 8.10, 95% CI 5.00–13.14), marital dissatisfaction (AOR 5.48, 95% CI 3.48–8.38), poor social support (AOR 4.70; 95% CI 2.99–7.38), past history of depression (AOR 4.67; 95% CI 2.47–8.80), previous pregnancy complication (AOR 2.50, 95% CI 1.57–3.89), low socio-economic status (AOR 2.41, 95% CI 1.61–3.66) and unplanned pregnancy (AOR 2.35, 95% CI 1.47–3.64).

Conclusions

The prevalence of antenatal depression is high with modifiable risk factors requiring context-specific policies such as provision of family, social and economic support for mothers at the earliest possible contact in the antenatal period.

Safe Pregnancy intervention for intimate partner violence: a randomised controlled trial in Norway among culturally diverse pregnant women

Background

Intimate partner violence (IPV) during pregnancy is a global health problem with adverse consequences for mothers, infants and families. We hypothesise that information about IPV and safety behaviours during pregnancy has the potential to increase quality of life and the use of safety behaviours and prevent IPV.

Methods

A multicentre randomised controlled trial among culturally diverse pregnant women in Norway, to test the effect of a tablet-based video intervention about IPV and safety behaviours. Women attending routine antenatal check-ups alone (baseline) were screened for violence (Abuse Assessment Screen) by responding to questions on a tablet, and randomised (1:1) by computer to receive an intervention or a control video. The intervention video presented information about IPV and safety behaviours. The controls viewed a video promoting healthy pregnancy in general. Outcome measures were assessed three months post-partum: The World Health Organization Quality of Life-BREF, the Composite Abuse Scale on violence during the last 12 months and use of safety behaviours based on a 15-item checklist. A general linear model for repeated measures was used to examine the intervention’s effect. The analyses were conducted by intention to treat.

Results

Among 1818 eligible women, 317 reported IPV and were randomised to an intervention (157) or a control group (160). A total of 251 (79.2%) women completed the follow-up questionnaire: 120 (76.4%) in the intervention group and 131 (81.9%) in the control group. At follow-up, 115 (45.8%) women reported a history of IPV. Few women (n = 39) reported IPV during the last 12 months. No differences in quality-of-life domains and overall quality of life and health were found between the intervention and the control groups. We detected no differences between the use of safety behaviours or IPV frequency and severity during the last 12 months.

Conclusion

Our intervention did not improve women’s quality of life, use of safety behaviours or exposure to violence. Nevertheless, a tablet-based tool may motivate women experiencing IPV to seek help and support. More research is needed regarding tablet-based interventions for women experiencing IPV, particularly culturally sensitive interventions.

Trial registration

NCT03397277 registered in clinicaltrials.gov on 11/01/2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04400-z.

The association between marital violence and reproductive and sexual health outcomes of women: A multi-country study of South Asia

In this study, we examined the relationship between marital violence(MV) and reproductive and sexual health outcomes of women of Bangladesh, India, Nepal and Pakistan. The lifetime MV inflicted by husbands on their wives was highest at 53% in Bangladesh, India(37%), Pakistan(28%) and Nepal(28%) respectively. Overall, our results in this study suggest that MV perpetrated by husbands on their wife is significantly associated with unintended pregnancy, pregnancy termination, current use of any modern contraceptive methods and sexually transmitted infections, but inconsistent associations are appeared across countries. Lifetime sexual violence and physical-sexual force were significantly and positively associated with unintended pregnancy and pregnancy termination respectively, whereas, all types of MV were significantly and positively related with the symptom of sexually transmitted diseases in the women. Appropriate measures should be undertaken to combat Violence against women(VAW) and necessary services should be provided to the victimized women to uphold their reproductive and sexual rights.

A way forward in the maternal mortality crisis: addressing maternal health disparities and mental health

Our objective was to review the role of maternal health disparities and mental health in the maternal mortality crisis in the USA, and discuss how perinatal care quality improvement in these areas is a critical lever for reducing maternal death. This paper summarizes content from a plenary talk delivered at the 2020 Biennial Meeting of the International Marcé Society for Perinatal Mental Health, in commemoration of the Society's 40th anniversary. The talk synthesized literature on two characteristics of the maternal mortality crisis in the US: (1) wide racial and ethnic disparities in maternal mortality and severe morbidity and (2) the impact of mental health and substance use disorders on maternal death, and introduced a framework for how health care quality gaps contribute to both of these issues. The US remains an outlier among similar nations in its alarmingly high rates of maternal mortality. Achieving significant progress on this measure will require confronting longstanding racial and ethnic disparities that exist throughout the pregnancy-postpartum continuum, as well as addressing the under-reported issue of maternal self-harm. Suicide and overdose are leading but under-recognized causes of death among pregnant and postpartum women in some states. Health care delivery failures, including inadequate risk assessment, care coordination, and communication, are identified in the literature on drivers of maternal health disparities and self-harm. Many of the same steps to improve quality of perinatal care can help to reduce health disparities and address the essential role of mental health in maternal well-being.

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.

Charting a Course towards Resilience Following Adverse Childhood Experiences: Addressing Intergenerational Trauma via Strengths-Based Intervention

Early research on adverse childhood experiences (ACEs) provided staggering evidence of the significant ramifications of ACEs on physical health and functioning. It brought to the forefront the importance of addressing trauma and family dysfunction to enhance public health. Over the past several decades, the study of childhood adversity has blossomed, with expanded conceptualizations and assessments of ACEs. This review brings together various biological, psychological, and sociological principles that inform our understanding of ACEs and our approach to treatment. Specifically, we document the evolution of ACEs research, focusing on the intergenerational impact of ACEs, the importance of incorporating a resilience framework when examining ACEs, and implementing interventions that address adversity across generations and at multiple levels of the social ecology. Evidence is provided to support the evolving perspective that ACEs have long-lasting effects beyond the ACE(s)-exposed individual, with significant attention to the impact of parental ACEs on child development. An intergenerational and multilevel approach to understanding and addressing ACEs offers specific areas to target in interventions and in public policy.

Longitudinal association between intimate partner violence and viral suppression during pregnancy and postpartum in South African women

OBJECTIVE

We examined the longitudinal association between women's exposure to intimate partner violence (IPV) and HIV viral load during pregnancy and postpartum.

DESIGN

Secondary analysis of an HIV-positive cohort enrolled during pregnancy at a South African antenatal clinic.

METHODS

Viral load was assessed at 10 study visits and analyzed continuously as log10 copies/ml and suppression at less than 50 copies/ml. IPV was measured at three timepoints using behaviorally specific items. We used multivariate logistic regression to examine the association between IPV and viral suppression, and cross-lagged dynamic panel modeling (DPMs) to estimate the longitudinal association between IPV (lagged by 3-6 months) and log10 viral load.

RESULTS

Of 471 women, 84% were virally suppressed by 6 weeks postpartum and 67% at 12 months postpartum. One-third reported IPV exposure. IPV victimization was not associated with viral suppression at delivery, but was associated with a reduced odds of viral suppression at 12 months postpartum (aOR = 0.48, 95% CI = 0.27-0.85). Findings were robust to sensitivity analyses at different timepoints and clinical cut-points. In DPMs, lagged IPV exposure was associated with higher log10 viral load after controlling for past viral load, duration on ART, age, alcohol use, and gestation at study enrolment. Each standardized increase in IPV intensity was associated with higher log10 viral load (standardized coefficient = 0.12, 95% CI = 0.05-0.23).

CONCLUSION

Although viral suppression was widely achieved during pregnancy, suppression rates declined postpartum in this South African cohort. These data suggest IPV is longitudinally associated with elevated viral load postpartum. Interventions for reducing exposure to IPV are important for the health of women and may improve HIV care and treatment.

The effect of solution-focused counseling on violence rate and quality of life of pregnant women at risk of domestic violence: a randomized controlled trial

BACKGROUND

Domestic violence during pregnancy as one of the most common social problems and major challenges of health systems can affect the health of the mother and fetus. The study aimed to compare the two groups of intervention based on solution-focused counseling and control in terms of violence and quality of life amounts in women who had experienced domestic violence.

METHODS

A randomized controlled trial on 90 pregnant women was blocked into two intervention groups (n = 45) and a control (n = 45). The intervention group received six counseling sessions with a solution-focused approach. Study tool included conflict tactics scale (CTS- 2) and short form health survey (SF-36). The tools were completed once before the intervention and again 6 weeks after the end of the counseling sessions by the participants of both groups. The P-value less than 0.05 was considered statistically significant.

RESULTS

A total of 82/90 pregnant women were analyzed. The results showed that median and interquartile range (IQR) of physical, psychological and sexual violence significantly decreased in the intervention group than the control group (Ps = 0.001). Moreover, quality of life scores significantly improved in the intervention group compared to the control group (P = 0.001).

CONCLUSION

Solution-focused counseling could be an effective approach to reduce the amount of violence and increase the quality of life in women exposed to domestic violence.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT2017040628352N4 . Date of registration: August 20th 2017.

Interventions Addressing Social Needs in Perinatal Care: A Systematic Review

Introduction: Health is impacted by a wide range of nonmedical factors, collectively termed the social determinants of health (SDoH). As the mechanisms by which these factors influence wellness and disease continue to be uncovered, health systems are beginning to assess their roles in addressing patient's social needs. This study seeks to identify and analyze clinic-based interventions aimed at addressing patients' social needs in perinatal care, including prenatal, antepartum, and postpartum care.

Methods: We conducted a search of six databases through May 2020 for articles describing screening or intervention activities addressing social needs in at least one SDoH domain as defined by Healthy People 2020. We required that studies include pregnant or postpartum women and be based in a clinical setting.

Results: Thirty-one publications describing 26 unique studies were identified. Most studies were either randomized-controlled trials (n=10) or observational studies (n=7) and study settings were both public and private. The mean age of women ranged from 17.4 to 34.1 years. Most studies addressed intimate partner violence (n=19). The next most common need addressed was social support (n=5), followed by food insecurity (n=3), and housing (n=2). Types of interventions varied from simple screening to ongoing counseling and case management. There was wide heterogeneity in outcomes investigated. Most IPV interventions that included counseling or ongoing support resulted in reduced IPV recurrence and severity. No intervention with only screening showed a reduction in rate of IPV.

Conclusion: This systematic review shines light on several avenues to support pregnant and postpartum women through interventions that embed acknowledgment of social needs and actions addressing these needs into the clinical environment. The results of this review suggest that interventions with counseling or ongoing support may show promise in alleviating social risk factors and improving some clinical outcomes. However, the strength of this evidence is limited by the paucity of studies. More rigorous research is imperative to augment the knowledge of social needs interventions, especially in domains outside of IPV.

Two-year follow up of a cluster randomised controlled trial for women experiencing intimate partner violence: effect of screening and family doctor-delivered counselling on quality of life, mental and physical health and abuse exposure

OBJECTIVES

This was a 2-year follow-up study of a primary care-based counselling intervention (weave) for women experiencing intimate partner violence (IPV). We aimed to assess whether differences in depression found at 12 months (lower depression for intervention than control participants) would be sustained at 24 months and differences in quality in life, general mental and physical health and IPV would emerge.

DESIGN

Cluster randomised controlled trial. Researchers blinded to allocation. Unit of randomisation: family doctors.

SETTING

Fifty-two primary care clinics, Victoria, Australia.

PARTICIPANTS

Baseline: 272 English-speaking, female patients (intervention n=137, doctors=35; control n=135, doctors=37), who screened positive for fear of partner in past 12 months. Twenty-four-month response rates: intervention 59% (81/137), control 63% (85/135).

INTERVENTIONS

Intervention doctors received training to deliver brief, woman-centred counselling. Intervention patients were invited to receive this counselling (uptake rate: 49%). Control doctors received standard IPV information; delivered usual care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Twenty-four months primary outcomes: WHO Quality of Life-Bref dimensions, Short-Form Health Survey (SF-12) mental health.

SECONDARY OUTCOMES

SF-12 physical health and caseness for depression and anxiety (Hospital Anxiety Depression Scale), post-traumatic stress disorder (Check List-Civilian), IPV (Composite Abuse Scale), physical symptoms (≥6 in last month). Data collected through postal survey. Mixed-effects regressions adjusted for location (rural/urban) and clustering.

RESULTS

No differences detected between groups on quality of life (physical: 1.5, 95% CI -2.9 to 5.9; psychological: -0.2, 95% CI -4.8 to 4.4,; social: -1.4, 95% CI -8.2 to 5.4; environmental: -0.8, 95% CI -4.0 to 2.5), mental health status (-1.6, 95% CI -5.3 to 2.1) or secondary outcomes. Both groups improved on primary outcomes, IPV, anxiety.

CONCLUSIONS

Intervention was no more effective than usual care in improving 2-year quality of life, mental and physical health and IPV, despite differences in depression at 12 months. Future refinement and testing of type, duration and intensity of primary care IPV interventions is needed.

TRIAL REGISTRATION NUMBER

ACTRN12608000032358.

Surveillance for Violent Deaths - National Violent Death Reporting System, 34 States, Four California Counties, the District of Columbia, and Puerto Rico, 2017

PROBLEM/CONDITION

In 2017, approximately 67,000 persons died of violence-related injuries in the United States. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on violent deaths that occurred in 34 states, four California counties, the District of Columbia, and Puerto Rico in 2017. Results are reported by sex, age group, race/ethnicity, method of injury, type of location where the injury occurred, circumstances of injury, and other selected characteristics.

PERIOD COVERED

2017.

DESCRIPTION OF SYSTEM

NVDRS collects data regarding violent deaths obtained from death certificates, coroner and medical examiner reports, and law enforcement reports. This report includes data collected for violent deaths that occurred in 2017. Data were collected from 34 states (Alaska, Arizona, Colorado, Connecticut, Delaware, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin), four California counties (Los Angeles, Sacramento, Shasta, and Siskiyou), the District of Columbia, and Puerto Rico. NVDRS collates information for each death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident.

RESULTS

For 2017, NVDRS collected information on 45,141 fatal incidents involving 46,389 deaths that occurred in 34 states, four California counties, and the District of Columbia; in addition, information was collected on 961 fatal incidents involving 1,027 deaths in Puerto Rico. Data for Puerto Rico were analyzed separately. Of the 46,389 deaths in the 34 states, four California counties, and District of Columbia, the majority (63.5%) were suicides, followed by homicides (24.9%), deaths of undetermined intent (9.7%), legal intervention deaths (1.4%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm deaths (<1.0%). (The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision, and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.) Demographic patterns and circumstances varied by manner of death. The suicide rate was higher among males than among females and was highest among adults aged 45-64 years and ≥85 years and non-Hispanic American Indians/Alaska Natives and non-Hispanic Whites. The most common method of injury for suicide was a firearm among males and poisoning among females. Suicide was most often preceded by a mental health, intimate partner, or physical health problem or a recent or impending crisis during the previous or upcoming 2 weeks. The homicide rate was highest among persons aged 20-24 years and was higher among males than females. Non-Hispanic Black males had the highest homicide rate of any racial/ethnic group. The most common method of injury for homicide was a firearm. When the relationship between a homicide victim and a suspect was known, the suspect was most frequently an acquaintance or friend for male victims and a current or former intimate partner for female victims. Homicide most often was precipitated by an argument or conflict, occurred in conjunction with another crime, or, for female victims, was related to intimate partner violence. Among intimate partner violence-related homicides, the largest proportion occurred among adults aged 35-54 years, and the most common method of injury was a firearm. When the relationship between an intimate partner violence-related homicide victim and a suspect was known, most female victims were killed by a current or former intimate partner, whereas approximately half of male victims were killed by a suspect who was not their intimate partner. Almost all legal intervention deaths were among males, and the legal intervention death rate was highest among men aged 25-29 years. Non-Hispanic American Indian/Alaska Native males had the highest legal intervention death rate, followed by non-Hispanic Black males. A firearm was used in the majority of legal intervention deaths. When a specific type of crime was known to have precipitated a legal intervention death, the type of crime was most frequently assault/homicide. The most frequent circumstances for legal intervention deaths were reported use of a weapon by the victim in the incident and a mental health or substance use problem (other than alcohol use). Unintentional firearm deaths more frequently occurred among males, non-Hispanic Whites, and persons aged 15-24 years. These deaths most often occurred while the shooter was playing with a firearm and most frequently were precipitated by a person unintentionally pulling the trigger or mistakenly thinking the firearm was unloaded. The rate of death when the manner was of undetermined intent was highest among males, particularly among non-Hispanic Black and non-Hispanic American Indian/Alaska Native males, and persons aged 30-34 years. Poisoning was the most common method of injury in deaths of undetermined intent, and opioids were detected in nearly 80% of decedents tested for those substances.

INTERPRETATION

This report provides a detailed summary of data from NVDRS on violent deaths that occurred in 2017. The suicide rate was highest among non-Hispanic American Indian/Alaska Native and non-Hispanic White males, whereas the homicide rate was highest among non-Hispanic Black males. Intimate partner violence precipitated a large proportion of homicides for females. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary circumstances for multiple types of violent death.

PUBLIC HEALTH ACTION

NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in developing, implementing, and evaluating programs and policies to reduce and prevent violent deaths. For example, South Carolina VDRS and Colorado VDRS are using their data to support suicide prevention programs through systems change and the Zero Suicide framework. North Carolina VDRS and Kentucky VDRS data were used to examine intimate partner violence-related deaths beyond homicides to inform prevention efforts. Findings from these studies suggest that intimate partner violence might also contribute to other manners of violent death, such as suicide, and preventing intimate partner violence might reduce the overall number of violent deaths. In 2019, NVDRS expanded data collection to include all 50 states, the District of Columbia, and Puerto Rico, providing more comprehensive and actionable violent death information for public health efforts to reduce violent deaths.

Perinatal mental health: a review of progress and challenges

Perinatal mental health has become a significant focus of interest in recent years, with investment in new specialist mental health services in some high-income countries, and inpatient psychiatric mother and baby units in diverse settings. In this paper, we summarize and critically examine the epidemiology and impact of perinatal mental disorders, including emerging evidence of an increase of their prevalence in young pregnant women. Perinatal mental disorders are among the commonest morbidities of pregnancy, and make an important contribution to maternal mortality, as well as to adverse neonatal, infant and child outcomes. We then review the current evidence base on interventions, including individual level and public health ones, as well as service delivery models. Randomized controlled trials provide evidence on the effectiveness of psychological and psychosocial interventions at the individual level, though it is not yet clear which women with perinatal mental disorders also need additional support for parenting. The evidence base on psychotropic use in pregnancy is almost exclusively observational. There is little research on the full range of perinatal mental disorders, on how to improve access to treatment for women with psychosocial difficulties, and on the effectiveness of different service delivery models. We conclude with research and clinical implications, which, we argue, highlight the need for an extension of generic psychiatric services to include preconception care, and further investment into public health interventions, in addition to perinatal mental health services, potentially for women and men, to reduce maternal and child morbidity and mortality.

User-Involvement in the Development of a Culturally Sensitive Intervention in the Safe Pregnancy Study to Prevent Intimate Partner Violence

Intimate partner violence (IPV) during pregnancy has negative health impacts on the woman and the fetus. There is a lack of evidence supporting effective interventions to prevent IPV during pregnancy. This user-involvement study was conducted to get feedback on a culturally sensitive, tablet intervention containing questions about violence and safety-behaviors and a video promoting safety behaviors. This resulted in important feedback on the intervention content. Our findings show that women are in favor of disclosing IPV via a tablet. They suggested ways to address barriers for disclosure, such as safeguarding anonymity and creating a trustful relationship with the midwife.

Women's Experiences of Domestic Violence during Pregnancy: A Qualitative Research in Greece

This qualitative research is the second part of a quantitative research that aims at recording the phenomenon of violence in pregnancy. The first part was carried out during August and September 2009 (N = 546). It was found out that the rate partner’s violence was 6%, while for 3.4% of the pregnant women, abuse started after the pregnancy. In the second part of this research, the semi-structured interview was used to investigate the way pregnant women experience violence. The sample comprised seven women abused by their partner (Ν = 7) at the women’s shelters of “Mitera” Babies’ Center and the National Social Solidarity Center between September 2010 and December 2011 and who accepted to participate in the research. The targets of the research were the investigation of the risk factors for the manifestation of violence, the profile of the victim and the perpetrator, the consequences of abuse for the woman, her reproductive health and the fetus. The majority of the abused pregnant women were foreigners and only two were Greek. The latter had experienced severe traumas (physical and psychological) since their childhood. Violence in their lives is the main characteristic of the foreign women seeking a better life in Greece, too. Alcohol use or abuse by the partners, poor socioeconomic background of the mothers and their partners, and pregnancy per se are the main risk factors of the violence against women in this period of their lives. Violence resulted in miscarriage in one case, while abortion was the alternative chosen by another as a solution to social exclusion and possible domestic violence. Anxiety and despair were the main psychological consequences. The small number of women included in the collection of qualitative data is a limitation for the research and decreases the reliability index of its results.

The Intersection of Maternal Morbidity and Mortality and Intimate Partner Violence in the United States

Background:

In the United States, rates of maternal morbidity and mortality (MMM) are high compared with other high-income countries and are characterized by significant racial/ethnic disparities. Typically, research on MMM focuses on obstetrical problems. Less research examines the role of intimate partner violence (IPV). Maternal health, IPV, and their intersection are linked with the impacts of social determinants of health.

Objective:

We sought to understand the intersection of MMM and IPV in the United States, particularly data issues that hinder research in this area and the resulting knowledge gaps.

Methods:

We identified major articles of interest regarding maternal morbidity and mortality and IPV in the United States and drafted a mini review based on relevant information.

Results:

Despite the prevalence of IPV during pregnancy, the intersection of maternal health and IPV has not been widely reviewed or discussed.

Conclusion:

There are a number of limitations in surveillance activities and data collection that underestimate the impact of IPV on MMM. Importantly, women who die by homicide or suicide— which in many cases is linked with IPV—are not counted as pregnancy-related deaths in the United States under the current definition. Establishing separate panels of local experts in maternal health or maternal mortality review committees (MMRCs) that are dedicated to examining violent deaths and use of the Maternal Mortality Review Information Application system would likely improve data accuracy of pregnancy-associated deaths. Based on the literature reviewed and limitations of current data, there are significant knowledge gaps on the effects of IPV and maternal health.

Effectiveness of Potential Interventions to Change Gendered Social Norms on Prevalence of Intimate Partner Violence in Uganda: a Causal Inference Approach

Evidence of the effectiveness of programs to change gendered social norms related to intimate partner violence (IPV) is growing, but their potential to significantly impact actual occurrence of IPV at population level is lacking. We study whether modest changes in gendered social norms related to wife-beating can result in significant changes in the incidence of emotional, physical, and sexual IPV among ever married women in Uganda. We employ an imputation-based causal inference approach, based on nationally representative Demographic Health Survey data. The steps are (1) model the association between adjusted neighborhood norms and experiences of IPV using a random effects logistic regression model, (2) impute unobserved counterfactual probabilities of experiencing IPV for each woman while manipulating her neighborhood norms by setting it to different values, (3) average the probabilities across the population, and (4) bootstrap confidence intervals. Results show that statistically significant inverse associations between more prohibitive neighborhood IPV norms and women's experiences of different forms of IPV at the population level exist. The effect is however small, that even if an entire community disapproves of wife-beating, incidence of IPV falls by about 10 percentage points to 48.5% (95% CI 46.0%-50.9%) from the observed value of 57.6% (95% CI 55.2%-59.9%). Furthermore, changes in neighborhood social norms are found to have no statistical significant effect on the incidence of sexual violence. In conclusion, changing gendered social norms related to wife-beating will not result in significant reductions in different forms for IPV at the population level.

Psychological therapies for women who experience intimate partner violence

BACKGROUND

Intimate partner violence (IPV) against women is prevalent and strongly associated with mental health problems. Women experiencing IPV attend health services frequently for mental health problems. The World Health Organization recommends that women who have experienced IPV and have a mental health diagnosis should receive evidence-based mental health treatments. However, it is not known if psychological therapies work for women in the context of IPV and whether they cause harm.

OBJECTIVES

To assess the effectiveness of psychological therapies for women who experience IPV on the primary outcomes of depression, self-efficacy and an indicator of harm (dropouts) at six- to 12-months' follow-up, and on secondary outcomes of other mental health symptoms, anxiety, quality of life, re-exposure to IPV, safety planning and behaviours, use of healthcare and IPV services, and social support.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, and three other databases, to the end of October 2019. We also searched international trials registries to identify unpublished or ongoing trials and handsearched selected journals, reference lists of included trials and grey literature.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and cross-over trials of psychological therapies with women aged 16 years and older who self-reported recent or lifetime experience of IPV. We included trials if women also experienced co-existing mental health diagnoses or substance abuse issues, or both. Psychological therapies included a wide range of interventions that targeted cognition, motivation and behaviour compared with usual care, no treatment, delayed or minimal interventions. We classified psychological therapies according to Cochrane Common Mental Disorders's psychological therapies list.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and undertook 'Risk of Bias' assessment. Treatment effects were compared between experimental and comparator interventions at short-term (up to six months post-baseline), medium-term (six to under 12 months, primary outcome time point), and long-term follow-up (12 months and above). We used standardised mean difference (SMD) for continuous and odds ratio (OR) for dichotomous outcomes, and used random-effects meta-analysis, due to high heterogeneity across trials.

MAIN RESULTS

We included 33 psychological trials involving 5517 women randomly assigned to experimental (2798 women, 51%) and comparator interventions (2719 women, 49%). Psychological therapies included 11 integrative therapies, nine humanistic therapies, six cognitive behavioural therapy, four third-wave cognitive behavioural therapies and three other psychologically-orientated interventions. There were no trials classified as psychodynamic therapies. Most trials were from high-income countries (19 in USA, three in Iran, two each in Australia and Greece, and one trial each in China, India, Kenya, Nigeria, Pakistan, Spain and UK), among women recruited from healthcare, community, shelter or refuge settings, or a combination of any or all of these. Psychological therapies were mostly delivered face-to-face (28 trials), but varied by length of treatment (two to 50 sessions) and staff delivering therapies (social workers, nurses, psychologists, community health workers, family doctors, researchers). The average sample size was 82 women (14 to 479), aged 37 years on average, and 66% were unemployed. Half of the women were married or living with a partner and just over half of the participants had experienced IPV in the last 12 months (17 trials), 6% in the past two years (two trials) and 42% during their lifetime (14 trials). Whilst 20 trials (61%) described reliable low-risk random-sampling strategies, only 12 trials (36%) described reliable procedures to conceal the allocation of participant status. While 19 trials measured women's depression, only four trials measured depression as a continuous outcome at medium-term follow-up. These showed a probable beneficial effect of psychological therapies in reducing depression (SMD -0.24, 95% CI -0.47 to -0.01; four trials, 600 women; moderate-certainty evidence). However, for self-efficacy, there may be no evidence of a difference between groups (SMD -0.12, 95% CI -0.33 to 0.09; one trial with medium-term follow-up data, 346 women; low-certainty evidence). Further, there may be no difference between the number of women who dropped out from the experimental or comparator intervention groups, an indicator of no harm (OR 1.04, 95% CI 0.75 to 1.44; five trials with medium-term follow-up data, 840 women; low-certainty evidence). Although no trials reported adverse events from psychological therapies or participation in the trial, only one trial measured harm outcomes using a validated scale. For secondary outcomes, trials measured anxiety only at short-term follow-up, showing that psychological therapies may reduce anxiety symptoms (SMD -0.96, 95% CI -1.29 to -0.63; four trials, 158 women; low-certainty evidence). However, within medium-term follow-up, low-certainty evidence revealed that there may be no evidence between groups for the outcomes safety planning (SMD 0.04, 95% CI -0.18 to 0.25; one trial, 337 women), post-traumatic stress disorder (SMD -0.24, 95% CI -0.54 to 0.06; four trials, 484 women) or re-exposure to any form of IPV (SMD 0.03, 95% CI -0.14 to 0.2; two trials, 547 women).

AUTHORS' CONCLUSIONS

There is evidence that for women who experience IPV, psychological therapies probably reduce depression and may reduce anxiety. However, we are uncertain whether psychological therapies improve other outcomes (self-efficacy, post-traumatic stress disorder, re-exposure to IPV, safety planning) and there are limited data on harm. Thus, while psychological therapies probably improve emotional health, it is unclear if women's ongoing needs for safety, support and holistic healing from complex trauma are addressed by this approach. There is a need for more interventions focused on trauma approaches and more rigorous trials (with consistent outcomes at similar follow-up time points), as we were unable to synthesise much of the research.

Problem solving therapy (PST) tailored for intimate partner violence (IPV) versus standard PST and enhanced usual care for pregnant women experiencing IPV in rural Ethiopia: protocol for a randomised controlled feasibility trial

BACKGROUND

In rural Ethiopia, 72% of women are exposed to lifetime intimate partner violence (IPV); IPV is most prevalent during pregnancy. As well as adversely affecting women's physical and mental health, IPV also increases the risk of child morbidity and mortality associated with maternal depression, thus making antenatal care an important opportunity for intervention. Adapting generic, task-shared, brief psychological interventions for perinatal depression and anxiety to address the needs and experiences of women affected by IPV may improve acceptability to women and feasibility for health workers. This randomised controlled feasibility trial will compare brief problem solving therapy (PST) specifically adapted for pregnant women experiencing IPV (PST-IPV) with standard PST and enhanced usual care to determine the feasibility of a future fully powered randomised controlled trial.

METHODS

Seventy-five pregnant women scoring five or more on the Patient Health Questionnaire, endorsing a tenth question about functional impact and reporting past-year IPV, will be recruited from antenatal care clinics in predominantly rural districts in Ethiopia. Consenting participants will be randomised to either four sessions of PST-IPV, four sessions of standard PST or information about sources of support (enhanced usual care) in a three-arm design. The interventions will be delivered by trained, supervised antenatal care staff using a task-sharing model. Assessments will be made at baseline and after 9 weeks by masked outcome assessors and will include measures of depression symptoms (primary outcome), post-traumatic stress, anxiety symptoms, functional impact, past-month IPV and hypothesised mediators (secondary outcomes). A mixed-method process evaluation will determine the feasibility of a future randomised controlled trial, assess the feasibility, acceptability, fidelity and quality of implementation of PST-IPV, generate testable hypotheses about causal mechanisms, and identify potential contextual factors influencing outcomes.

DISCUSSION

Despite mental health being a critical concern for women experiencing IPV, there is limited evidence for brief, task-shared psychological interventions adapted for their needs in low- and middle-income countries. Contextually tailored interventions for pregnant women experiencing IPV in low- and middle-income countries require development and process evaluation. This randomised controlled feasibility trial will yield results on the feasibility of conducting a fully powered trial, relevant to researchers, primary and antenatal care clinicians in resource-limited settings.

TRIAL REGISTRATION

Pan-African clinical trials registry: PACTR202002513482084. Prospectively registered on 13 December 2019.

Midwives' Attitudes Toward and Experience With a Tablet Intervention to Promote Safety Behaviors for Pregnant Women Reporting Intimate Partner Violence: Qualitative Study

BACKGROUND

Violence against women is considered a global health problem, and intimate partner violence (IPV) around the time of childbirth can have severe consequences for mother and child. Prenatal care is considered a window of opportunity to address IPV and ask women about exposure to violence since women are in regular contact with health care providers. Mobile health (mHealth) interventions might overcome the barriers to talking about IPV face-to-face.

OBJECTIVE

Our objective was to explore midwives' attitudes toward a tablet intervention consisting of information about IPV and safety behaviors as well as their experiences with recruiting pregnant women of different ethnic backgrounds in a randomized controlled trial (RCT).

METHODS

Individual interviews were conducted with 9 midwives who recruited participants for an RCT to test a video to promote safety behaviors delivered on a tablet during prenatal care. Analysis was guided by thematic analysis.

RESULTS

Midwives perceived the tablet intervention as an appropriate supplement during prenatal care to provide information about IPV and promote safety behaviors. They participated in the RCT primarily to obtain more knowledge regarding how to communicate about IPV. The intervention was perceived as an anonymous door-opener to talk about IPV and a good solution to ensure that every woman gets the same information. However, the content of the intervention had to be trustworthy and align with the information the midwives provide to women. Given the sensitivity of IPV, midwives outlined the importance of following the intervention with face-to-face communication. Midwives reported technical problems and a high demand on their time as the main challenges to recruiting women. They experienced challenges recruiting women of different ethnic backgrounds due to linguistic barriers and the women's skepticism about scientific research.

CONCLUSIONS

The tablet intervention might help midwives communicate about IPV. Although the video was considered as an anonymous door-opener to talk about IPV, midwives outlined the importance of following the intervention with face-to-face communication. The scarcity of midwives' time during consultations has to be considered when implementing the intervention. Further research is needed to overcome barriers that limit inclusion of women from different ethnic backgrounds.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03397277; https://clinicaltrials.gov/ct2/show/NCT03397277.

Midwives' Attitudes Toward and Experience With a Tablet Intervention to Promote Safety Behaviors for Pregnant Women Reporting Intimate Partner Violence: Qualitative Study

Background

Violence against women is considered a global health problem, and intimate partner violence (IPV) around the time of childbirth can have severe consequences for mother and child. Prenatal care is considered a window of opportunity to address IPV and ask women about exposure to violence since women are in regular contact with health care providers. Mobile health (mHealth) interventions might overcome the barriers to talking about IPV face-to-face.

Objective

Our objective was to explore midwives’ attitudes toward a tablet intervention consisting of information about IPV and safety behaviors as well as their experiences with recruiting pregnant women of different ethnic backgrounds in a randomized controlled trial (RCT).

Methods

Individual interviews were conducted with 9 midwives who recruited participants for an RCT to test a video to promote safety behaviors delivered on a tablet during prenatal care. Analysis was guided by thematic analysis.

Results

Midwives perceived the tablet intervention as an appropriate supplement during prenatal care to provide information about IPV and promote safety behaviors. They participated in the RCT primarily to obtain more knowledge regarding how to communicate about IPV. The intervention was perceived as an anonymous door-opener to talk about IPV and a good solution to ensure that every woman gets the same information. However, the content of the intervention had to be trustworthy and align with the information the midwives provide to women. Given the sensitivity of IPV, midwives outlined the importance of following the intervention with face-to-face communication. Midwives reported technical problems and a high demand on their time as the main challenges to recruiting women. They experienced challenges recruiting women of different ethnic backgrounds due to linguistic barriers and the women’s skepticism about scientific research.

Conclusions

The tablet intervention might help midwives communicate about IPV. Although the video was considered as an anonymous door-opener to talk about IPV, midwives outlined the importance of following the intervention with face-to-face communication. The scarcity of midwives’ time during consultations has to be considered when implementing the intervention. Further research is needed to overcome barriers that limit inclusion of women from different ethnic backgrounds.

Trial Registration

ClinicalTrials.gov NCT03397277; https://clinicaltrials.gov/ct2/show/NCT03397277

A Systematic Review of Intimate Partner Violence Interventions: State of the Field and Implications for Practitioners

Intimate partner violence (IPV) victimization is a global public health issue and has serious consequences of women's health. While scholars and researchers have made some progress in addressing IPV and its impact across different levels of care, there is a paucity of intervention research in this area. For example, we know little about which intervention models work best for particular groups of IPV survivors. Previous reviews have concluded there is insufficient evidence to recommend specific treatment options for victims, but they have also been limited in scope of target populations or have employed narrow eligibility criteria. This systematic review examined the efficacy and effectiveness of interventions for victims of IPV related to physical and mental health and revictimization. Three large databases were searched and articles were selected using specified criteria. Fifty-seven articles met inclusion criteria. Results indicate that both empowerment-based advocacy and cognitively focused clinical interventions demonstrate positive outcomes on the vast sequelae of violence in the context of an intimate relationship. The heterogeneity of intervention approaches and frameworks makes comparisons across studies challenging, but this review demonstrates that interventions focused on problem-solving/solution seeking, enhanced choice making and the alteration in distorted self-thinking and perception are promising in facilitating and maintaining positive physical and mental health changes for women who experience violence.

'We don't see because we don't ask': Qualitative exploration of service users' and health professionals' views regarding a psychosocial intervention targeting pregnant women experiencing domestic and family violence

Introduction

Given the relative recency of Domestic and Family Violence (DFV) management as a field of endeavour, it is not surprising that interventions for addressing DFV is still in its infancy in developing countries. In order to maximise the success of an intervention, it is important to know which aspects of the intervention are considered important and helpful by service providers and service users. This study, therefore, examined the acceptability of an antenatal-based psychosocial intervention targeting DFV in Nepal and explored suggestions for improving the program in future.

Materials and methods

Intervention participants and health care providers (HCPs) were interviewed using semi-structured interviews. Data were audio-recorded and thematic analysis was used to analyse the data. Final codes and themes were identified using an iterative review process among the research team.

Results

Themes emerging from the data were grouped into domains including perceptions towards DFV, impact of the intervention on women’s lives and recommendations for improving the program. DFV was recognised as a significant problem requiring urgent attention for its prevention and control. Intervention participants expressed that they felt safe to share their feelings during the counselling session and got opportunity to learn new skills to cope with DFV. The majority of the participants recommended multiple counselling sessions and a continued provision of the service ensuring the intervention’s accessibility by a large number of women.

Discussion

This is the first study to document the perspectives of women and HCPs regarding an antenatal-based intervention targeting psychosocial consequences of DFV in Nepal. There was a clear consensus around the need to engage, support and empower victims of DFV and the intervention was well received by the participants. Ensuring good mental health and wellbeing among victims of DFV requires work across individual, organisational and community levels.

Understanding the Needs and Preferences of Domestic and Sexual Violence Education for Health Profession Students

This study examined health profession students' comfort levels, perceived knowledge, attitudes, and preferences for domestic and sexual violence education at an academic medical center. Students indicated their perceived knowledge of community resources was poor, whereas comfort, attitudes, and perceived knowledge of the topic remained fair. A majority of students (83.2%) reported receiving less than 3 hr of training in their coursework, which remained consistent for students with more years of education. Students preferred content be incorporated into existing curricula or presented in lunch seminars. Study results reveal opportunities for improvement in domestic and sexual violence education.

Integrated Multicomponent Interventions for Safety and Health Risks Among Black Female Survivors of Violence: A Systematic Review

The epidemic of violence disproportionately affects women, including Black women. Black women survivors of violence have been found to face multiple safety and health issues such as depression, post-traumatic stress disorder, HIV, and poor reproductive health. Many health issues co-occur, and this co-occurrence can be associated with additional safety and health-related challenges for survivors. Consequently, there is a need for multicomponent interventions that are designed to concurrently address multiple health issues commonly faced by Black survivors of violence. This systematic review of literature determines the efficacy of various strategies used in the existing evidence-based multicomponent interventions on violence reduction, promotion of reproductive health, reduction in risk for HIV, reduction in levels of stress, and improvement in mental health. Sixteen intervention studies were identified. Examples of components found to be efficacious in the studies were safety planning for violence, skill building in self-care for mental health, education and self-regulatory skills for HIV, mindfulness-based stress reduction for reducing stress, and individual counseling for reproductive health. Although some strategies were found to be efficacious in improving outcomes for survivors, the limitations in designs and methods, and exclusive focus on intimate partner violence calls for more rigorous research for this population, particularly for Black survivors of all forms of violence. There is also need for culturally responsive multicomponent interventions that account for diversity among Black survivors.

Intimate Partner Violence Screening and Intervention: The American College of Preventive Medicine Position Statement

The purpose of this paper is to produce a position statement on intimate partner violence (IPV), a major sociomedical problem with recently updated evidence, systematic reviews, and U.S. Preventive Services Task Force guidelines. This position statement is a nonsystematic, rapid literature review on IPV incidence and prevalence, health consequences, diagnosis and intervention, domestic violence laws, current screening recommendations, barriers to screening, and interventions, focusing on women of childbearing age (15-45 years). The American College of Preventive Medicine (ACPM) recommends an integrated system of care approach to IPV for screening, identification, intervention, and ongoing clinical support. ACPM only recommends screening that is linked to ongoing clinical support for those at risk. ACPM recommends greater training of clinicians in IPV screening and interventions and offers health systems and research recommendations.

Surveillance for Violent Deaths - National Violent Death Reporting System, 32 States, 2016

PROBLEM/CONDITION

In 2016, approximately 65,000 persons died in the United States as a result of violence-related injuries. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) regarding violent deaths from 32 U.S. states for 2016. Results are reported by sex, age group, race/ethnicity, type of location where injured, method of injury, circumstances of injury, and other selected characteristics.

PERIOD COVERED

2016.

DESCRIPTION OF SYSTEM

NVDRS collects data regarding violent deaths obtained from death certificates, coroner/medical examiner reports, law enforcement reports, and secondary sources (e.g., child fatality review team data, Supplementary Homicide Reports, hospital data, and crime laboratory data). This report includes data collected from 32 states for 2016 (Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Utah, Vermont, Virginia, Washington, and Wisconsin). NVDRS collates information for each death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident.

RESULTS

For 2016, NVDRS captured 40,374 fatal incidents involving 41,466 deaths in the 32 states included in this report. The majority (62.3%) of deaths were suicides, followed by homicides (24.9%), deaths of undetermined intent (10.8%), legal intervention deaths (1.2%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm deaths (<1.0%). (The term legal intervention is a classification incorporated into the International Classification of Diseases, Tenth Revision [ICD-10] and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.) Demographic patterns varied by manner of death. Suicide rates were highest among males, non-Hispanic American Indians/Alaska Natives, non-Hispanic whites, adults aged 45-64 years, and men aged ≥75 years. The most common method of injury was a firearm among males and poisoning among females. Suicides were most often preceded by a mental health, intimate partner, substance abuse, or physical health problem or a recent or impending crisis during the previous or upcoming 2 weeks. Homicide rates were highest among males and persons aged <1 year and 15-44 years. Among males, non-Hispanic blacks accounted for most homicides and had the highest rate of any racial/ethnic group. The most common method of injury was a firearm. Homicides were most often precipitated by an argument or conflict, occurred in conjunction with another crime, or for females, were related to intimate partner violence. When the relationship between a homicide victim and a suspected perpetrator was known, the suspect was most frequently an acquaintance/friend among males and a current or former intimate partner among females. Legal intervention death rates were highest among men aged 20-44 years, and the rate among non-Hispanic black males was three times the rate among non-Hispanic white males. Precipitating circumstances for legal intervention deaths most frequently were an alleged criminal activity in progress, reported use of a weapon by the victim in the incident, a mental health or substance abuse problem (other than alcohol abuse), an argument or conflict, or a recent or impending crisis. Unintentional firearm deaths were more frequent among males, non-Hispanic whites, and persons aged 15-24 years. These deaths most often occurred while the shooter was playing with a firearm and most often were precipitated by a person unintentionally pulling the trigger or mistakenly thinking the firearm was unloaded. Rates of deaths of undetermined intent were highest among males, particularly non-Hispanic black and American Indian/Alaska Native males, and adults aged 25-64 years. Substance abuse, mental health problems, physical health problems, and a recent or impending crisis were the most common circumstances preceding deaths of undetermined intent. In 2016, a total of 3,655 youths aged 10-24 years died by suicide. The majority of these decedents were male, non-Hispanic white, and aged 18-24 years. Most decedents aged 10-17 years died by hanging/strangulation/suffocation (49.3%), followed by a firearm (40.4%), and suicides among this age group were most often precipitated by mental health, family relationship, and school problems. Most suicides among decedents aged 18-24 years were by a firearm (46.2%), followed by hanging/strangulation/suffocation (37.4%), and were precipitated by mental health, substance abuse, intimate partner, and family problems. A recent crisis, an argument or conflict, or both were common precipitating circumstances among all youth suicide decedents.

INTERPRETATION

This report provides a detailed summary of data from NVDRS for 2016. Suicides rates were highest among non-Hispanic American Indian/Alaska Native and white males, whereas homicide rates were highest among non-Hispanic black males. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary precipitating events for multiple types of violent deaths, including suicides among youths aged 10-24 years.

PUBLIC HEALTH ACTION

NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in the development, implementation, and evaluation of programs and policies to reduce and prevent violent deaths. For example, Utah VDRS data were used to help identify suicide risk factors among youths aged 10-17 years, Rhode Island VDRS suicide data were analyzed to identify precipitating circumstances of youth suicides over a 10-year period, and Kansas VDRS data were used by the Kansas Youth Suicide Prevention Task Force. In 2019, NVDRS expanded data collection to include all 50 states, Puerto Rico, and the District of Columbia. This expansion is essential to public health efforts to reduce violent deaths.

Generating CHARISMA: Development of an Intervention to Help Women Build Agency and Safety in Their Relationships While Using PrEP for HIV Prevention

This article describes the development of the Community Health clinic model for Agency in Relationships and Safer Microbicide Adherence intervention (CHARISMA), an intervention designed to address the ways in which gender norms and power differentials within relationships affect women's ability to safely and consistently use HIV pre-exposure prophylaxis (PrEP). CHARISMA development involved three main activities: (1) a literature review to identify appropriate evidence-based relationship dynamic scales and interventions; (2) the analysis of primary and secondary data collected from completed PrEP studies, surveys and cognitive interviews with PrEP-experienced and naïve women, and in-depth interviews with former vaginal ring trial participants and male partners; and (3) the conduct of workshops to test and refine key intervention activities prior to pilot testing. These steps are described along with the final clinic and community-based intervention, which was tested for feasibility, acceptability, and preliminary effectiveness in Johannesburg, South Africa.