Back to Screen Show Presentation Index

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Review Medical History

Warning signs of IPV may include:

• Previous medical visits for injuries
• History of abuse or assault
• Repeated visits
• Chronic pelvic pain, headaches, vaginitis, irritable bowel syndrome
• History of depression, substance use, suicide attempts, anxiety

Notes:

These are some of the warning signs that might be found in medical charts.

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Recent studies of the screening practices of physicians, including obstetrician–gynecologists, indicate that most conduct screening for violence only when warning signs are observed.^16,17

Unfortunately, violence can exist in the absence of warning signs in the patient’s medical history or behavior. Women who are victims of violence may not present with symptoms, especially those who experience psychologic or emotional abuse. They may conceal what they are experiencing at home. For these reasons, it is essential to screen every patient routinely. ACOG and other organizations strongly encourage screening of all women at routine, regular intervals.¹²

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Review Medical History

Pregnancy-related factors, such as:

• Unintended pregnancy
• Unhappiness about being pregnant
• Young maternal age
• Single marital status
• Higher parity
• Late entry into prenatal care/missed appointments
• Substance use or abuse (tobacco, alcohol, or drugs)

Notes:

Although there are still many unanswered questions about whether violence and pregnancy are directly associated, some maternal characteristics have been identified as being more prevalent among women who report violence. These factors—such as tobacco, alcohol, or drug use or abuse—may, in turn, lead to negative pregnancy outcomes.

(Read slide text)

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Observe Women's Behavior

• Flat affect
• Fright, depression, anxiety
• Post-traumatic stress disorder (PTSD) symptoms:
  • dissociation
  • psychic numbing
  • startle responses
• Overcompliance
• Excessive distrust

Notes:

A woman’s behavior during office visits also can provide warning signs for possible intimate partner violence. Abused women may present with a flat affect or as frightened, depressed, or anxious. Severe cases may be characterized by symptoms of post-traumatic stress disorder (PTSD), such as dissociation, psychic numbing, or startle responses to touch.11,12

Abused women may appear overly compliant. Most pregnant patients have a number of questions, but an abused woman may have “learned” not to question authority. Conversely, an abused woman may exhibit excessive distrust of health care providers, possibly because of the fear and shame associated with the abuse and the possibility of its detection.

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Observe Partner's Behavior

• Being overly solicitous
• Answering questions for the patient
• Being hostile or demanding
• Never leaving the patient's side
• Monitoring the woman's responses to quesitons

Notes:

The behavior of the husband or partner during prenatal visits also may indicate that a woman is at high risk for intimate partner violence. An abusive partner’s behaviors during office visits might include:

(Read slide text)

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Ask Directly

• Ask questions in private
  • apart from male partner
  • apart from family and friends
• Explain issues of confidentiality
• Be aware of mandatory reporting laws in your safe state and inform the women of them

Notes:

Because partner control is a key factor in violence and abuse, it is essential to ask questions in private, apart from the male partner and apart from children, family, or friends. It is especially important to avoid using family or friends as an interpreter when asking these questions. 

Begin by explaining issues of confidentiality, but also be aware of any mandatory reporting laws in your state. State domestic violence and child protection agencies can provide information about state laws. For your state, please contact___________________. (Instructor, insert state contact information, usually found in the government section of your local telephone directory.)

(NOTE: Please provide state contact information, usually found in the government section of your local telephone directory). 

Have a plan to inform the woman of how you will handle the information she provides.

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Ask Directly

Violence is a problem for many women. Because it affects health and well-being. I ask all my patients about it.

Notes:

It helps to introduce screening questions with a statement that will help the patient understand that you are not singling her out. For example: 

(Read slide text)

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Open the Door

• Find your own way of phrasing questions
• Be prepared to hear your patient's answer
• Face-to-face talk is more effective that written patient questionnaires

Notes:

The point of asking questions directly is to open the door of communication. You will find your own way of phrasing questions. The key is to to convey to the patient that you are prepared to hear her answer—no matter what that answer is.

Research has shown that asking women direct questions in a face-to-face assessment is more effective than asking women about violence in a written questionnaire.18 One recent study of physicians indicates that although disclosure may not occur at the time of screening, caring and empathetic questioning may open the door for later disclosure.7

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Abuse Assessment Screen

• Short
• Tested in clinical settings
• Effective in identifying violence

Notes:

Many different screening tools and strategies have been developed. One of the most widely used and the one we recommend incorporating into your routine health screening is the Abuse Assessment Screen.19 This tool is short and has been tested in clinical settings. The Abuse Assessment Screen has been proven to be as effective as longer interviews in identifying victims of violence. 20

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Abuse Assessment Screen

1. In the last year (since I saw you last), have you been hit, slapped, kicked, or otherwise physically hurt by someone? (If yes, by who,? Number of times? Nature of injury?)
2. Since you've been pregnant, have you been hit slapped, kicked, or otherwise physically hurt by someone? (If yes, by whom? Number of times? Nature of injury?)

Notes:

The four questions in the Abuse Assessment Screen are: 

(Read slide text and continue to next slide)

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Abuse Assessment Screen

3. Within the last year has anyone made you do something sexual that you didn't want to do? (If yes, who?)
4. Are you afraid of your partner or anyone else?

Notes:

(Read slide text)

It is important to recognize that intimate partner violence can begin at any point during a pregnancy. Therefore, it is important to screen multiple times, such as during each trimester and at the postpartum exam. The questions can be adapted for use in follow-up screenings.

Date last reviewed: 03/21/2006
Content source: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion