Ms. J is a patient I know well. I saw her throughout her first pregnancy and attended the birth of her daughter. Now, two years later she is pregnant again, but this time with a different partner, who she refers to with much ambivalence as her “baby daddy.” At first, Ms. J seemed equally ambivalent about the pregnancy, but became more excited when she learns the baby is a boy.
At 28 weeks of pregnancy Ms. J tells me she has filed a restraining order against the boyfriend, because he came after her with a crowbar. His family tells her she has a problem, that she is bipolar, and that she has provoked the man. Ms. J is questioning whether they are right and if she should “give him another chance.”
Ms. D is another patient I know well. Pregnant with her third baby at 23 years old, her husband and two very young sons attend every prenatal visit with her. She is thrilled to be having a girl this time, but often expresses her anxiety about having three babies, so close together and has inquired about postpartum tubal ligation, despite her husband’s desire to have more children and his obvious annoyance every time Ms. D asks about it.
During one prenatal visit, her husband takes the boys out of the exam room to change a diaper. I take this brief rare moment alone to ask about any violence at home. Ms. D whispers that he has been “getting mean” and tried to choke her. She reports calling the police, but is not willing to get a restraining order. “It’s my fault” she said, “I always provoke him.”
Ms. J and Ms. D are just two examples of the many pregnant women who are victims of intimate partner violence (IPV). It is estimated that between 4% and 8% of pregnant women are victims of IPV. These women are at increased risk for pregnancy complications, poor maternal and newborn health outcomes and death.
Despite recommendations for universal screening for IPV from every major obstetric and medical organization, providers are inconsistent with screening. Sadly, this is particularly true during pregnancy.
So why aren’t we routinely screening women, particularly pregnant women for IPV? Time constraints are the major reason most providers give for not screening. Other reasons include discomfort with the topic, doubt that women will actually disclose the abuse, and lack of knowledge about how to help victims of IPV.
There are plenty of IPV screening tools available to providers, ranging from a few short questions to much longer inventories. But there is no one “gold standard” IPV screening tool, according to the U.S. Preventive Services Task Force (USPSTF). The CDC offers a helpful provider resource of brief IPV screening tools for use in the healthcare setting.
What should you do when you discover your patient is a victim of IPV? First, listen and reassure the woman that this is not her fault, and she does not deserve to be abused in any way. Take the time to ask if she feels safe, and help her develop a safety plan, or assist in contacting law enforcement. Be knowledgeable about local resources, such as shelters and advocacy groups, as well as any state laws that mandate reporting of IPV. Document what the woman tells you along with any visible signs of abuse.
Many providers are afraid of offending patients by asking about abuse or violence. But the more comfortable a provider becomes with asking questions regarding IPV, the more routine it will become. Ask the screening questions in your own words and document all responses. Attend any provider training or classes available on IPV.
Often a question asked during one visit will open the lines of communication in future visits. Be observant of patient and partner behavior. Screen all pregnant women for physical, sexual and emotional abuse at their first prenatal visit, and at least once a trimester as well as during the postpartum visit. Helping a woman identify all the available support systems, including family, friends, law enforcement, advocacy groups and healthcare providers can provide her with options and choices she didn’t know were available.
Robyn Carlisle, MSN, CNM, WHNP, works as a full-scope midwife at University Doctors and Kennedy University Hospital in Sewell, N.J.
- Basile KC, Hertz MF, Back SE. “Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings: Version 1.” Atlanta, GA: Centers for Disease Control and Prevention; 2007.
- Centers for Disease Control and Prevention. “Intimate Partner Violence During Pregnancy, A Guide for Clinicians: Download Instructions.” Training PowerPoint.