Ohio Department of Health June 2009 Volume 1, Issue 1 PRAMS News Confronting Intimate Partner Violence National Impact and Definitions Intimate partner violence (IPV) is a leading cause of injury to American women between the ages of 15 and 44. (1) Up to 25 percent of all hospital emergency room visits made by women each year are due to injury resulting from abuse by a former or current partner. According to some estimates, one in six pregnant women will be abused during pregnancy. (2,3) And homicide has recently sur‐ Inside this issue passed motor vehicle accidents and falls as the leading cause of injury death during pregnancy. Frequency of IPV in Ohio 1 IPV Screening 2 Abuse during pregnancy can have potentially serious consequences for mother, IPV Screening in Ohio 2 fetus and newborn. These include miscarriage, placental abruption, stillbirth, premature labor, fetal injury and low birth weight. (4,5) Additional health prob‐ Abused but not Screened 3 lems related IPV are unintended pregnancy, STD and/or HIV transmission and Practices and Barriers 3 exacerbation of chronic health problems from trauma‐related stress. Further‐ Domestic Violence Protocol 4 more, behaviors that negatively impact fetal and maternal health, such as smok‐ ing and misuse of alcohol and other substances, are often coping strategies for What is Ohio PRAMS? 6 living in abusive relationships. (6) Special Insert 7 The U.S. Centers for Disease Control and Prevention defines IPV as physical, sex‐ ual or psychological harm caused by a current or former partner or spouse, that may vary in frequency and severity ranging from one incident to chronic, severe Characteristics Associated battering. It occurs among heterosexual or same‐sex couples and does not re‐ with Abuse During Preg‐ quire sexual intimacy. (7) IPV is characterized by patterns of physical, sexual, nancy, Ohio, 2004‐20071 emotional and/or economic abuse inflicted to establish power or control in the relationship. (8) • Black (cOR= 2.6, 95% CI: 1.8 ‐ 3.5) • Age less than 20 years 2 (cOR= 2.0, 95% CI: 1.4‐3.1) What Does PRAMS Tell Us About IPV in Ohio? • Education less than high school (cOR= 2.9, 95% CI: 1.9‐4.5) An estimated 8,929 Ohio women who gave birth to a live infant in 2007, or 6.2 • Medicaid for prenatal care (cOR= 4.0, 95% CI: 2.8‐5.8) percent (95% CI: 4.8‐8.1), reported having experienced IPV in the 12 months • Unmarried before pregnancy, while 4.2 percent (95% CI: 3.0‐5.7) reported such abuse took (cOR= 4.8, 95% CI: 3.2‐7.2) place during the pregnancy. From 2004 through 2007, maternal characteristics • Pregnancy unintended associated with abuse during pregnancy included black race, age younger than (cOR= 2.5, 95% CI: 1.7‐3.6) 20 years, unmarried status, less than a high school education, Medicaid cover‐ age for prenatal care and unintended pregnancy. However, after simultaneous 1cOR =crude (unadjusted) odds ratio 2 adjustment for these factors, only black race (aOR=1.5, 95% CI: 1.1‐2.2), Medi‐ aOR =adjusted odds ratio caid (aOR=2.0, 95% CI: 1.3‐3.3) and unmarried status (aOR=2.6, 95% CI: 1.4‐4.5) remained significantly associated with IPV during pregnancy. IPV Screening Recommendations The American Col‐ medical exams are justified by the existence of a high lege of Obstetricians prevalence of undetected abuse. They argue that rou‐ and Gynecologists tine screening is a low‐cost and effective method for (ACOG) recommends identifying victims of IPV, whose desire for help may IPV screening of all change over time. Left unaddressed, the severity and women, including frequency of abuse can worsen over time, leading to during pregnancy at serious health and potentially life‐threatening conse‐ the first prenatal quences. (10) Furthermore, in surveys of women who visit, at least once were physically abused, 92 percent stated they did not per trimester, and at discuss these incidents with their physicians, (11‐13) yet the postpartum four different studies demonstrated that the majority of checkup. (9) Univer‐ abused women would like their health care provider to sal IPV screening is ask them privately about IPV. (13,15,16,17) also endorsed by the U. S. Surgeon Gen‐ Most Ohioans are seen at some point by a health pro‐ eral, American Asso‐ fessional. The health care setting offers a critical oppor‐ ciation of Family tunity for early detection and primary prevention of Practitioners, Ameri‐ abuse. Since neither victims nor batterers have been can Medical Association, American Nurses Association, American Public Health Association, Joint Commission found to fit a distinct personality profile, universal on Accreditation of Health Care Facilities, National Asso‐ screening is more appropriate than targeting specific ciation for Social Workers and the National Institutes of patient populations. (10, 11) Thus, it is not only impor‐ Medicine. tant that medical, legal, and social service workers are trained to recognize the symptoms of IPV, but also that The U.S. Prevention Services Task Force has stated that effective screening tools are consistently applied where routine IPV questions directed toward women during appropriate. IPV Screening of Ohio Pregnant Women1, 2 The Ohio PRAMS questionnaire asked, “During any of your prenatal care vis‐ Characteristics Associated with Screening for IPV Dur­ its, did a doctor, nurse, or other health care worker talk with you about ing Prenatal Care, Ohio, …....physical abuse to women by their husbands or partners?” In response, 1 2004­2007 during the period 2004‐2007, 47.7 percent of mothers (95%CI: 46.0‐49.5) indicated that a provider had this discussion with them. Characteristics asso‐ • Black race ciated with having had an IPV discussion were largely the same as those re‐ (cOR=2.7, 95% CI: 2.3‐3.2) lated to experiencing IPV during pregnancy (see sidebar at left). After simul‐ • Age less than 20 years (cOR=1.6, 95% CI: 1.3‐2.0) taneous adjustment for such factors in a logistic regression model, character‐ • Education less than high istics significantly associated with IPV screening included black race school (aOR=1.9, 95% CI: 1.6‐2.3), Medicaid coverage (aOR=1.5, 95% CI: 1.2‐1.8), (cOR=2.4, 95% CI: 1.9‐2.9) unmarried status (aOR=1.7, 95% CI: 1.3‐2.0) and education less than high • Medicaid for prenatal care (cOR=2.3, 95% CI: 1.9‐2.6) school (aOR=1.8, 95% CI: 1.4‐2.3). • Unmarried (cOR=2.4, 95% CI: 2.1‐2.8) Despite similarities in characteristics of women likely to be abused versus • Unintended pregnancy screened for IPV, those who reported abuse during pregnancy were no more (cOR=1.6, 95% CI: 1.4‐1.8) likely to have had an IPV conversation with a provider than women who did 1cOR =crude (unadjusted) odds ratio not report such abuse (cOR=1.4, 95% CI: 1.0‐1.9 ), suggesting the inability of 2aOR =adjusted odds ratio providers to correctly predict actual victims of IPV. Among the women who 2 were abused during pregnancy, 45 percent (95%CI: 36.8‐53.5) reported that a provider did not have an IPV conversation with them during prenatal care. Thus, by failing to adhere to universal IPV screening recommendations, from 2004 through 2007, prenatal care providers in Ohio missed potential prevention oppor‐ tunities for an estimated 10,185 women who suffered abuse during pregnancy but did Abused Ohio birth mothers not have an IPV conversation with a provider. Characteristics of these abused but un‐ who were not screened for IPV during prenatal care screened women are found below. were likely to: • Be unmarried Characteristics of Mothers Reporting Abuse During Pregnancy Who Were • Have prenatal care be‐ Not Screened for IPV During Prenatal Care, Ohio PRAMS, 2004­2007 ginning in the first tri‐ mester Not Married 73.4 • Have an unintended Prenatal Care in First Trimester 84.9 pregnancy • Have high school or Pregnancy Not Intended 69.0 greater educational at‐ tainment High School or Above 71.6 • Be age 20 years or older Medicaid Coverage 72.9 • Have prenatal care cov‐ ered by Medicaid Age 20 and Over 78.6 • Be from a racial group Race Other than Black 71.4 other than African‐ American 0 102030405060708090 Percent Barriers to IPV Screening Screening Practices and Barriers (18‐23) Similar to results from Ohio PRAMS, studies have shown health professionals • Inadequate knowledge largely do not adhere to universal IPV screening recommendations. For example, and training in a 2004 Arizona study of physicians, just 22 percent of respondents indicated they screened female patients “frequently” or “always.” (18) A survey of obstetri‐ • Lack of time cian‐gynecologists reported domestic violence screening rates of 27 percent of non • Belief there is a lack of ‐pregnant and 39 percent of pregnant females. (19) This same study found that community resources screening was most likely to occur when obstetricians‐gynecologists suspected for victims abuse, both during pregnancy (68 percent) and when the patient was not pregnant (72 percent). Similarly, Roelens et al. found obstetricians‐gynecologists largely un‐ • Feeling discomfort in derestimated the extent of the IPV problem. (20) In this study, some believed they asking patients were able to recognize domestic violence when it existed, favoring opportunistic over universal screening. • Feeling powerless to help the victim Studies of provider attitudes about IPV screening have concluded that the quality • Belief that screening of provider training is the strongest predictor of a positive attitude toward IPV wasn’t their responsi‐ screening and referral. (24,25) Health care providers had favorable opinions to‐ bility ward additional education and practice to enhance their skills in communicating and responding to abuse disclosures.