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Coercive Control and Intimidation

• Acts perceived by recipients as violent or threatening
• Recipient's fear of attack or retliation
• Threat alternated with kindness

Notes:

Coercive control and intimidation by the abusive partner is considered an underlying component of all of these types of violence. Acts are considered to be violent if they are perceived by the recipient as violent or threatening. Much of the abusive partner’s ability to control relies on the abused person’s belief that if she does not comply, either she, her children, or other persons or things she cares about will come under attack.

Often, threats are alternated with acts of kindness from the perpetrator, making it all the more difficult for the victim to break free of the cycle of violence.

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Violence and Pregnancy

• At least 4–8% of women report violence during pregnancy
• As many ass 324,00 women who gave birth in 1998 experienced violence

Notes:

Now that we have defined intimate partner violence, what about its link to pregnancy? 

In a CDC review, researchers found that depending on the population, setting, or frequency of asking, between 0.9 and 20.1% of women reported experiencing violence during pregnancy. In 8 of 11 of these studies, 4–8% of women reported experiencing violence during pregnancy.3

Using this conservative range of prevalence, of the 4 million women who delivered live-born infants in 1998, between 152,000 and 324,000 would have experienced violence during pregnancy. This number is similar to estimates in previous years and does not include the number of women who had pregnancies that did not result in a live birth. 

Researchers have not yet been able to determine definitively whether violence actually begins, ends, or increases during pregnancy. They also have not been able to determine if it continues throughout pregnancy or begins in the postpartum period. More research is needed to replicate the studies that have explored each of these time frames.

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Violence and Pregnancy

Violence during pregnancy may be more common than:

• Gestational diabetes
• Neural tube defects
• Preclampsia

Notes:

We know that violence during pregnancy may be more common than some conditions for which most pregnant women are routinely screened.3 As with screening for gestational diabetes, neural tube defects, preeclampsia, and behavioral risk factors such as smoking and alcohol use, screening for intimate partner violence should be incorporated into routine prenatal care.

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Possible Demographic and Psychosocial Factors

• Young maternal age/adolescence
• Unintended pregnancy
• Delayed prenatal care
• Smoking
• Alcohol and drug use
• Lack of social supports
• STD/HIV/AIDS

Notes:

Women who report violence around the time of pregnancy also have reported higher prevalence of some demographic and psychosocial risk factors that also may have an effect on pregnancy. These include: 

(Read slide text) 

Although there is no single profile of an abused woman, it should be noted that adolescents are at increased risk for violence—from either their partner or from a family member. Women with HIV or AIDS are also at increased risk for violence.

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Possible Effects on Fetus

• Direct effects
  • spontaneous abortion
  • fetal injury or death from maternal trauma
• Indirect effects
  • maternal stress
  • materanl smoking
  • alcohol or drug use or abuse

Notes:

No consistent research findings indicate whether fetal health is affected by violence.9 Severe cases of physical abuse are known to have direct effects on the fetus. An example would be fetal injury or death associated with trauma to the mother. 

In addition, fetal health could be affected indirectly through maternal stress, smoking, or alcohol or drug use or abuse—all of which might be responses to the violence itself. These conditions and behaviors are known to be associated with poor outcomes such as low birth weight, intrauterine growth restriction, and fetal alcohol syndrome.

Moreover, women in abusive relationships may find it difficult or impossible to fulfill prenatal care recommendations such as frequency of visits, prescribed supplements, nutrition, STD prevention, or substance-abuse recovery programs.

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Possible Risks for Children

• Violence may involve other household members
• Witnessing violence is a risk factor for abusive relationships as an adult
• Child abuse is associated with depression, substance abuse, poor school performance, high-risk sexual activity.

Notes:

Intimate partner violence often is associated with abuse of other household members, particularly children. Research indicates that violence is a learned behavior, and witnessing violence in the home as a child is a strong risk factor for involvement in abusive relationships as an adult.¹⁰ 

In addition, experiencing abuse as a child has been associated with other risk factors such as depression, substance abuse, poor school performance, and high-risk sexual activity.^11,12 

Clinicians have an opportunity not only to identify and intervene on behalf of the abused woman, but also to assist in breaking the intergenerational cycle that could affect her children. Whenever possible, at the point of detection, clinicians should communicate with the family’s other health care providers, such as pediatricians. Clinicians should also be aware of and follow state reporting requirements related to domestic violence or child abuse and neglect.

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Barriers to Screening

• Time constraints
• Discomfort with the topic
• Fear of offending the patient or partner
• Perceived powerlessness to change the problem

Notes:

Although pregnancy offers an important opportunity to screen for violence, most women report that they are not asked about violence during pregnancy.13

When providers are asked why they do not screen for violence, they commonly indicate four major barriers.14

(Read slide text) 

Provider training in the use of efficient assessment methods can help overcome these barriers. The following information can help health care organizations and individual providers increase competency in and commitment to screening for violence.

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Use Your "RADAR"

• Routinely screen every patient
• Ask directly, kindly, nonjudgementallly
• Document your findings
• Assess the patient's safety
• Review options and provide referrals

Notes:

Steps in screening and intervention can be summarized in the acronym RADAR, which was developed by the Massachusetts Medical Society.¹⁵

The first step in the RADAR process is to routinely screen for violence. Assume that all patients are at risk for violence and ask every patient as part of her routine health assessment. Screening requires that the provider ask directly for information at multiple visits throughout the pregnancy. 

In cases where violence is identified, document your findings in the patient’s chart. Assess your patient’s safety—is she or are her children in immediate danger? Finally, review the patient’s options and provide her with referrals.

The next slides will take you through each of these steps in greater detail.

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Routinely Screen Every Patient

• At first prenatal visit
• At least once per trimester
• At postpartum checkup
• At routine ob-gyn visits and preconception visits

Notes:

Screening should occur at various times over the course of the pregnancy because some women do not disclose abuse the first time they are asked and abuse may begin later in pregnancy. 12,16 

Screening should occur at the first prenatal visit, at least once per trimester, and at the postpartum checkup. 

For women who are not pregnant, screening should occur at routine ob-gyn visits, family planning visits, and at preconception visits.

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Components of Screening

• Review medical history
• Observe and record presentations and behaviors of patient and partner
• Ask direct questions and listen actively
• Document patient's response

Notes:

Screening for violence has a number of components. First, review the woman’s medical history. Observe presentations and behaviors of the patient and her partner. Ask direct questions to assess her risk for violence and listen actively. Always document the patient’s response, even when it is “no.”

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