Policy Background
Domestic Violence Screenings in Obstetric Healthcare Settings
Globally, incident rates of domestic violence during pregnancy or postpartum vary tremendously. Geography, demographic information, and research methods all contribute to this disparity. The range is between 5% and up to 80%, with a smaller range of 10-20% on average in the United States.[1],[2],[3] This is a higher rate than many other pregnancy-related health outcomes which are consistently screened during healthcare visits.
Women who experience abuse during pregnancy have an increased risk of homicide that lasts at least 24 months postpartum.[4] Domestic violence has an effect on pregnancy-related deaths even beyond those directly linked to homicide, which highlights the importance of utilizing multiple opportunities for intervention. Domestic violence can contribute to or exacerbate PTSD, anxiety, depression, and substance use disorder.[5],[6] Abuse can increase stress levels which increases the risk of other health outcomes. Experiencing domestic violence during pregnancy is correlated to medical conditions that increase the risk of mortality, including miscarriage or spontaneous abortion, antepartum hemorrhage, preterm labor, and delayed intrauterine growth.[7],[8] Abuse is also a barrier to seeking medical care. Women who experience domestic violence are twice as likely to miss prenatal appointments or delay seeking prenatal care, which can exacerbate other issues or prevent intervention on serious health complications.[9]
There is evidence that resource referrals that result from screenings reduce the rates of domestic violence homicide, negative health outcomes, and reinjury.[10],[11],[12],[13] Providers and practitioners identify many barriers to using screening tools or initiating conversations about domestic abuse during appointments, however, which results in missed opportunities for intervention.[14] One of the most common concerns relates to provider knowledge of and attitudes toward domestic abuse.[15] These attitudes can mean a provider feels uncomfortable asking questions, doesn’t understand the questions they are asking or the impact they have, and can result in a lack of follow-up referrals or support for positive screenings.[16] Another barrier to successful screening practices is the use of screening tools that have shown mixed efficacy. Many screening tools only look at particular forms of violence, and often exclude sexual abuse, stalking, and coercive control.[17] This means many survivors of abuse are not identified and thus do not receive relevant, life-saving services. Providers often identify resource-related and legal concerns as reasons for not screening for domestic abuse, expressing concern about potential litigation or increased billing.[18] However, the same providers also report that they do screen for other health issues, or regularly screen for domestic abuse with specific populations, which demonstrates the role of provider biases in screening practices.[19],[20]
Despite these barriers, comprehensive screening in a healthcare setting is a common recommendation within studies on domestic abuse during pregnancy or the prevention of domestic violence homicide.[21],[22] Recommendations include healthcare providers working with women to identify what they need following disclosure of domestic abuse, coordinating referrals and working to reduce barriers to accessing care, and having existing intervention programs, resources, and housing available within a community.[23],[24],[25] Increased provider knowledge and understanding of domestic abuse, the effects of abuse on pregnancy, referral sources, and trauma-informed care can also improve screening practices.
Most issues related to screening efficacy relate to what happens after a screening.[26] Across studies, there are low rates of referrals to specific domestic abuse-related services. This lack of follow-up can make screening appear to be a less significant intervention when assessing reinjury rates, continued abuse, or homicide outcomes.[27] In one meta-analysis, only 32% of those who screened positive for DV were referred to follow-up services.[28] In that same study, of the 32% who were referred to follow-up services, a median of 54% actually pursued or attended those services. Increasing the number screened and improving the relevancy of referred services would bridge this gap.
Identified risks or negative outcomes of screening predominantly relate to feelings of discomfort on the part of the patient. These results were found in a small percentage of those screened, while the majority reported appreciating the questions and feeling more understood by their provider as a result of the screening.[29],[30] Factors related to the screening impact these outcomes, with more open-ended questions and stronger provider knowledge leading to more positive perceptions of the experience.[31] Studies also have not indicated long-term or domestic abuse-related negative health outcomes as a result of screening practices. Negative outcomes related to patient discomfort can be ameliorated by increasing provider competency and familiarity with these topics.
Some groups and consortiums recommend screening only in instances where there are obvious risk factors or if a provider has suspicions that domestic abuse may be present.[32] However, there are concerns about this recommendation. It assumes a level of knowledge or understanding of the dynamics of domestic abuse that research repeatedly shows is not ubiquitous to healthcare providers.[33] This practice can lead to biases or assumptions about who is abused, and a narrow scope as to what abuse can entail. Studies show that biases related to race and class heavily impact screening.[34] Black, Indigenous, and other Women of Color, low-income, young, and unpartnered women are shown to be both over- and under-screened for domestic abuse compared to the general population.[35],[36] Standardizing domestic violence screenings in pregnancy-related clinical visits can prevent these disparities, increase feelings of trust or cultural awareness, and facilitate more connections between survivors and relevant services.
[1] Román-Gálvez, R. M., Martín-Peláez, S., Martínez-Galiano, J. M., Khan, K. S., & Bueno-Cavanillas, A. (2021). Prevalence of intimate partner violence in pregnancy: an umbrella review. International journal of environmental research and public health, 18(2), 707.
[2] Román-Gálvez, R. M., Martín-Peláez, S., Fernández-Félix, B. M., Zamora, J., Khan, K. S., & Bueno-Cavanillas, A. (2021). Worldwide Prevalence of Intimate Partner Violence in Pregnancy. A Systematic Review and Meta-Analysis. Frontiers in public health, 1278.
[3] Cizmeli, C., Lobel, M., Harland, K. K., & Saftlas, A. (2018). Stability and change in types of intimate partner violence across pre-pregnancy, pregnancy, and the postpartum period. Women's Reproductive Health, 5(3), 153-169.
[4] Noursi, S., Clayton, J. A., Campbell, J., & Sharps, P. (2020). The intersection of maternal morbidity and mortality and intimate partner violence in the United States. Current Women's Health Reviews, 16(4), 298-312.
[5] Campbell, J., Matoff-Stepp, S., Velez, M. L., Cox, H. H., & Laughon, K. (2021). Pregnancy-associated deaths from homicide, suicide, and drug overdose: Review of research and the intersection with intimate partner violence. Journal of Women's Health, 30(2), 236-244.
[6] Chisholm, C. A., Bullock, L., & Ferguson II, J. E. J. (2017). Intimate partner violence and pregnancy: epidemiology and impact. American journal of obstetrics and gynecology, 217(2), 141-144.
[7] Martin-de-Las-Heras, S., Velasco, C., Luna-del-Castillo, J. D. D., & Khan, K. S. (2019). Maternal outcomes associated to psychological and physical intimate partner violence during pregnancy: A cohort study and multivariate analysis. PLoS one, 14(6), 1-11.
[8] Musa, A., Chojenta, C., Geleto, A., & Loxton, D. (2019). The associations between intimate partner violence and maternal health care service utilization: a systematic review and meta-analysis. BMC women's health, 19(1), 1-14.
[9] McFarlane, J., Maddoux, J., Cesario, S., Koci, A., Liu, F., Gilroy, H., & Bianchi, A. L. (2014). Effect of abuse during pregnancy on maternal and child safety and functioning for 24 months after delivery. Obstetrics & Gynecology, 123(4), 839-847.
[10] Burnett, C., Crowder, J., Bacchus, L. J., Schminkey, D., Bullock, L., Sharps, P., & Campbell, J. (2021). “It Doesn’t Freak Us Out the Way It Used to”: An Evaluation of the Domestic Violence Enhanced Home Visitation Program to Inform Practice and Policy Screening for IPV. Journal of interpersonal violence, 36(13-14), 7488-7515.
[11] Bacchus, L. J., Bullock, L., Sharps, P., Burnett, C., Schminkey, D. L., Buller, A. M., & Campbell, J. (2016). Infusing technology into perinatal home visitation in the United States for women experiencing intimate partner violence: exploring the interpretive flexibility of an mHealth intervention. Journal of medical Internet research, 18(11), 302-332.
[12] Noursi, S. et al., 2020.
[13] Aboutanos, M. B., Altonen, M., Vincent, A., Broering, B., Maher, K., & Thomson, N. D. (2019). Critical call for hospital-based domestic violence intervention: The Davis Challenge. Journal of trauma and acute care surgery, 87(5), 1197-1204.
[14] Chisholm, C. A., Bullock, L., & Ferguson II, J. E. J. (2017). Intimate partner violence and pregnancy: screening and intervention. American journal of obstetrics and gynecology, 217(2), 145-149.
[15] O’Reilly, R., & Peters, K. (2018). Opportunistic domestic violence screening for pregnant and post-partum women by community based health care providers. BMC women's health, 18(1), 1-8.
[16] Heron, R. L., & Eisma, M. C. (2021). Barriers and facilitators of disclosing domestic violence to the healthcare service: a systematic review of qualitative research. Health & Social Care in the Community, 29(3), 612-630.
[17] Ibid.
[18] Kapaya, M., Boulet, S. L., Warner, L., Harrison, L., & Fowler, D. (2019). Intimate partner violence before and during pregnancy, and prenatal counseling among women with a recent live birth, United States, 2009–2015. Journal of Women's Health, 28(11), 1476-1486.
[19] Halpern-Meekin, S., Costanzo, M., Ehrenthal, D., & Rhoades, G. (2019). Intimate partner violence screening in the prenatal period: variation by state, insurance, and patient characteristics. Maternal and child health journal, 23(6), 756-767.
[20] Taillieu, T. L., Brownridge, D. A., & Brownell, M. (2020). Screening for partner violence in the early postpartum period: are we missing families most at risk of experiencing violence?. Canadian journal of public health, 111(2), 286-296.
[21] Robinson, S. R., Maxwell, D., & Williams, J. R. (2019). Qualitative, Interpretive Metasynthesis of Women’s Experiences of Intimate Partner Violence During Pregnancy. Journal of Obstetric, Gynecologic & Neonatal Nursing, 48(6), 604-614.
[22] Chaves, K., Eastwood, J., Ogbo, F. A., Hendry, A., Jalaludin, B., Khanlari, S., & Page, A. (2019). Intimate partner violence identified through routine antenatal screening and maternal and perinatal health outcomes. BMC pregnancy and childbirth, 19(1), 1-10.
[23] Noursi, S. et al., 2020.
[24] McLemore, M. R., Altman, M. R., Cooper, N., Williams, S., Rand, L., & Franck, L. (2018). Health care experiences of pregnant, birthing and postnatal women of color at risk for preterm birth. Social Science & Medicine, 201, 127-135.
[25] Bianchi, A. L., Cesario, S. K., & McFarlane, J. (2016). Interrupting intimate partner violence during pregnancy with an effective screening and assessment program. Journal of Obstetric, Gynecologic & Neonatal Nursing, 45(4), 579-591.
[26] Alhusen, J. L., Ray, E., Sharps, P., & Bullock, L. (2015). Intimate partner violence during pregnancy: maternal and neonatal outcomes. Journal of women's health, 24(1), 100-106.
[27] Van Parys, A. S., Deschepper, E., Roelens, K., Temmerman, M., & Verstraelen, H. (2017). The impact of a referral card-based intervention on intimate partner violence, psychosocial health, help-seeking and safety behaviour during pregnancy and postpartum: a randomized controlled trial. BMC pregnancy and childbirth, 17(1), 1-16.
[28] Miller, C. J., Adjognon, O. L., Brady, J. E., Dichter, M. E., & Iverson, K. M. (2021). Screening for intimate partner violence in healthcare settings: An implementation-oriented systematic review. Implementation Research and Practice, 2(1), 1-47.
[29] Creedy, D. K., Baird, K., & Gillespie, K. (2020). A cross-sectional survey of pregnant women’s perceptions of routine domestic and family violence screening and responses by midwives: Testing of three new tools. Women and birth, 33(4), 393-400.
[30] Correa, N. P., Cain, C. M., Bertenthal, M., & Lopez, K. K. (2020). Women’s experiences of being screened for intimate partner violence in the health care setting. Nursing for women's health, 24(3), 185-196.
[31] Spangaro, J. (2017). What is the role of health systems in responding to domestic violence? An evidence review. Australian health review, 41(6), 639-645.
[32] Chisholm, C.A. et al., 2017.
[33] Smith, R., Wight, R., & Homer, C. S. (2018). ‘Asking the hard questions’: Improving midwifery students’ confidence with domestic violence screening in pregnancy. Nurse education in practice, 28, 27-33.
[34] Jones, K. M., Carter, M. M., Bianchi, A. L., Zeglin, R. J., & Schulkin, J. (2020). Obstetrician-gynecologist and patient factors associated with intimate partner violence screening in a clinical setting. Women & Health, 60(9), 1000-1013.
[35] Kapayam M. et al., 2019.
[36] Halpern-Meekin, S. et al., 2019.