Intimate partner violence during pregnancy: best practices for social workers.
Intimate partner violence (IPV) during pregnancy is a major problem
in the United States, with estimates that 3 percent to 17 percent of
women experience violence during the perinatal period. Research
indicates that IPV during pregnancy is associated with serious, negative
health outcomes for the mother and her unborn child. As such, many
researchers have suggested that pregnancy offers a unique window for IPV
intervention, particularly for social workers in health-care settings.
Although assessing for IPV more generally has received increased
attention in the social work literature, there is a lack of information
about the specific needs for pregnant women. Thus, the purpose of this
article is to provide a focused literature review on the scope and
impact of IPV during pregnancy and to identify best practices for social
workers for intervention and prevention.
KEY WORDS: domestic violence; intimate partner violence; pregnancy; social work interventions; universal screening
Pregnant women (Health aspects)
Social workers (Practice)
Social case work (Methods)
Family violence (Prevention)
Family violence (Social aspects)
Family violence (Health aspects)
Armstrong, D'edra Y.
|Publication:||Name: Health and Social Work Publisher: Oxford University Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Sociology and social work Copyright: COPYRIGHT 2012 Oxford University Press ISSN: 0360-7283|
|Issue:||Date: Feb, 2012 Source Volume: 37 Source Issue: 1|
|Topic:||Event Code: 290 Public affairs; 200 Management dynamics|
|Product:||Product Code: 9101226 Domestic Violence (Families) NAICS Code: 92219 Other Justice, Public Order, and Safety Activities|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
Intimate partner violence (IPV) during pregnancy is a major problem
in the United States, with anywhere from 3 percent to 17 percent of
pregnant women reported as victims (Gazmararian et al., 1996; Jeanjot,
Barlow, & Rozenberg, 2008). Most alarming is a national study
reporting that among pregnant women in the United States, homicide is
the second most prevalent cause of traumatic death. In addition,
research indicates a number of other poor health and mental health
outcomes for both mother and child when IPV occurs during pregnancy (see
Taylor & Nabors, 2009, for a review).
Social workers in health-care settings are especially likely to encounter survivors of IPV, as pregnancy is identified as a time when women tend to exhibit increased awareness of their own health and that of their children and are, therefore, more likely to come into contact with health-care systems (Shadigian & Bauer, 2005). As such, prenatal care visits offer a critical opportunity to identify and address IPV (American College of Obstetricians and Gynecologists [ACOG], 2009; Pulido, 2001). In practice, however, fewer than 10 percent of health-care practitioners routinely screen for IPV (Rodriguez, Bauer, McLoughlin, & Grumbach, 1999). In addition, fewer than 50 percent of obstetricians and gynecologists routinely screen for IPV (National Coalition Against Domestic Violence [NCADV], 2006), despite strong recommendations that such screening be performed.
To date, there is little information on the percentage of social workers who routinely screen for IPV in health-care settings. A study by Tower (2003) found that although nearly 92 percent of medical social workers (n = 188) reported identifying a victim of IPV in their practice, only 35.6 percent had "nearly always" or "always" screened for IPV within the prior three months. In addition to screening, social workers have the opportunity to influence the issue of IPV and pregnancy at multiple levels, including the provision of effective services to survivors. Social work practice is, therefore, especially important in the assessment, intervention, referral, prevention, policymaking, and research processes related to IPV and pregnancy (Murphy & Ouimet, 2008). Despite the critical role that social workers can play in addressing the problem of IPV and pregnancy, there is a dearth of information available on best practices. Therefore, the purpose of this article is to provide a review of the literature on the scope and impact of IPV during pregnancy and to identify best practices for social workers for intervention.
SOCIAL WORK AND IPV
The definition of IPV varies widely, but it is commonly conceptualized as a pattern of coercive behaviors in a relationship whereby one person uses tactics of power and control over another person over a period of time (Danis & Bhandari, 2010). The Centers for Disease Control and Prevention (CDC) define IPV as a public health problem that includes physical, sexual, emotional, or psychological abuse and threats of harm (CDC, 2009). Others have emphasized the need to include financial abuse, controlling behaviors, and coercion as forms of IPV (Stark, 2007). Perinatal IPV is defined as abuse that occurs before, during, or up to one year after pregnancy (Sharps, Laughon, & Giangrande, 2007).
Over the past decade, greater efforts have been made to prepare social workers to address IPV generally through evaluation, observation, and screening (Danis, 2003). Some researchers, however, maintain that social workers are failing to use universal screening techniques to identify IPV survivors and their children in their caseloads. For example, Lindhorst, Meyers, and Casey (2008) noted that despite a high prevalence of IPV among welfare recipients, studies examining screening practices in welfare offices using the Temporary Assistance for Needy Families (TANF) family violence option have reported that only 9.3 percent of case encounters included screening for IPV. In addition, D. G. Saunders, Holter, Pahl, Tolman, and Kenna (2005) investigated screening for IPV by TANF workers and found that lack of disclosure on the part of victims might be related to worker discomfort or lack of skills or could be directly related to victim reluctance. Jeanjot et al. (2008) investigated screening practices among health-care professionals. They found that, as with social workers, health-care providers are not systematically screening for IPV, although in many instances they come into contact with victims shortly after the abuse occurs. In another study, fewer than 10 percent of health-care providers reported routinely screening for IPV, with reported obstacles including language and cultural barriers, fear of shocking the patient, and lack of confidence in ability to manage the problem (Rodriguez et al., 1999).
Although assessing for IPV more generally has received increased attention in the social work literature, there is a lack of information about the specific needs of pregnant women. Related disciplines such as nursing, however, provide a wealth of information on the critical elements of working with pregnant survivors of IPV. Social workers can use this information to provide a foundation for recognizing their essential role in working with women who experience IPV during pregnancy. As such, the purpose of this study was to review the relevant literature on IPV during pregnancy so as to provide a road map for social workers to understand the role they might have.
Our analysis was a focused literature review, conducted to determine information about interventions for IPV and pregnancy and their the scope and impact. The first step of the review was to determine key words that would yield relevant articles. The primary search terms were based on a preliminary review of the literature and chosen in consultation with experts in the field. They included the following: "domestic violence," "intimate partner violence," "domestic violence and pregnancy," "IPV and pregnancy," "IPV prevalence," "IPV and homicide," "social work," "risk factors," "IPV intervention," and "universal screening." These key words were used to conduct a search of the literature using the Social Work Abstracts, Sociological Abstracts, Social Services Abstract, and Family and Society Studies Worldwide databases for English-language, full-length, peer-reviewed articles published between September 1990 and August 2010. In addition to full-length articles, dissertations and posters presented at professional conferences during this period were also reviewed. National reports and protocols from established agencies (for example, the CDC) that were cited repeatedly in studies were also examined and included in the present review.
We developed appropriate inclusion criteria on the basis of the objectives of the study. The criteria were operationalized to include information on victims and perpetrators, pregnancy- and health-related outcomes, risk factors, intervention, effective screening during pregnancy, the role of the social work profession in regard to IPV, and policy implications. Duplicate data sets, single-event case reports, and studies conducted outside the United States were excluded. The scope of the present review was limited to data and recommendations based on a U.S. population only.
Each article was reviewed to determine if it met the inclusion criteria. Of the 156 articles reviewed, 70 were included in the analysis because they met one or more criteria. Once the articles were identified, they were reviewed in their entirety and summarized by Sarah McMahon and then reviewed by D'edra Y. Armstrong. A deductive approach was primarily used to gather information about the categories determined previously, including the prevalence of IPV during pregnancy, risk factors, health- and pregnancy-related outcomes, and effective intervention approaches. Articles were coded according to these themes, and then a constant comparative process was used (Patton, 1990). Information for each theme was synthesized, noting the methodological strengths and weaknesses of the information to provide a context for interpretation.
Prevalence of IPV during Pregnancy
Many studies investigating the prevalence of IPV during pregnancy not only examined the actual months of pregnancy, but also included the year prior to the pregnancy and one year postpartum. Although a growing body of literature does point to an increase in IPV during pregnancy, the literature is mixed on the direction of the relationship. Some studies have found that in relationships with no prior IPV, the abuse is initiated during pregnancy (Anderson, Marshak, & Hebbeler, 2002; Crawford, 2007, Gazmararian et al., 2000). Some authors have hypothesized that this greater risk for IPV occurs because of the physical, emotional, and financial vulnerability of the pregnant woman (Saltzman, Johnson, Gilbert, & Goodwin, 2003). Other studies have linked the greater risk for IPV during pregnancy to the psychological status of the perpetrator, including increased stress over having to support a baby, anger over an unplanned pregnancy, and jealousy that the partner's attention may have shifted to the baby (Brewer & Paulsen, 1999).
Other studies have found that in those relationships in which IPV was already occurring, it escalated during pregnancy. For example, Silverman, Decker, Reed, and Raj (2006) reported that women who experienced IPV in the year prior to or during a recent pregnancy were 40 percent to 60 percent more likely to have pregnancy-related problems than were pregnant women who were not abused. Using data on a nationally representative cohort of pregnant women in U.S. cities, Charles and Perriera (2007) found that, overall, 33 percent of mothers experienced some form of IPV (physical, emotional, or sexual) during pregnancy or in the first year postpartum. In addition, in a prospective study of pregnant women with HIV and those without, Koenig (2006) found that 61.7 percent experienced IPV only during their pregnancy, supporting the notion that IPV increases considerably during pregnancy.
Other researchers, however, found that with the onset of pregnancy, the severity and frequency of IPV decreases. In a study in 51 prenatal patients who experienced IPV in their relationships, researchers found that the risk for homicide in these abused women significantly decreased with the onset of pregnancy (Decker, Martin, & Moracco, 2002). According to data obtained from the Pregnancy Risk Assessment Monitoring System, the reported range of IPV in the year before giving birth was 2.9 percent to 5.7 percent (CDC, 2009), which is much lower than data reported in other research. Jasinski and Kantor (2001) used data from the National Alcohol and Family Violence Survey and found that--after controlling for socioeconomic status, stressful life events, and age--pregnancy was not a significant risk factor for violent victimization among pregnant women, not just women in general. It is important to note that this particular study examined physical IPV only, not taking into account psychological or other forms of IPV. Another study found that although pregnancy onset was associated with increased rates of psychological aggression, pregnancy was not associated with significant increases in physical IPV or violence-related injuries (Martin et al., 2004).
In sum, the literature contains mixed findings concerning whether pregnancy is a risk factor for IPV and whether IPV increases in severity during pregnancy. These discrepancies might be due to a number of factors. First, various measures were used, and IPV was defined differently from study to study. The timeframe defined as "pregnancy" also varied, with some studies including up to one year pre- or postdelivery. Second, researchers have recognized a difference in prevalence rates dependent on whether national or community samples are used, with community samples reporting more abuse than national samples (Bailey & Daugherty, 2007;Jasinski, 2004).
Although there is no consensus as to the primary cause or potential risk of abuse during pregnancy, the literature does attempt to identify some risk factors. Studies have identified both demographic and behavioral risk factors for the victim and the perpetrator.
Demographic Risk Factors. For the victim, the most significant demographic predictors for IPV during pregnancy documented in the literature are low socioeconomic status or income (Bailey, 2010; Saltzman et al., 2003), low education level (Bohn, Tebben, & Campbell, 2004), single (nonmarried) status (Anderson et al., 2002; Saltzman et al., 2003), and young age (Saltzman et al., 2003; Straus & Gelles, 1990). The role of race and ethnicity as an influence in IPV is not well documented, with some studies finding African American women to be at a greater risk (Chu, Goodwin, & D'Angelo, 2010; Silverman et al., 2006) and others finding Hispanic women to be at a greater risk for IPV during pregnancy (Charles & Perreira, 2007). Studies that further investigated how race and ethnicity influence the occurrence and progression of IPV both generally and specific to pregnancy are warranted (Taylor & Nabors, 2009).
The occurrence of IPV during pregnancy has also been associated with other high-risk behaviors by the mother, including engaging in substance abuse and having sex with multiple partners (Koenig, 2006; Lipsky, Holt, Esterling, & Critchlow, 2005; Martin, Beaumont, & Kupper, 2003). Studies have also documented family dynamics as playing a significant role in the risk for IPV during pregnancy, with women at a greater risk when they are unmarried or cohabitating (Taylor & Nabors, 2009), are separated or divorced (Chu et al., 2010), report negative interactions with their intimate partner, receive less support from the father (Sagrestano, Carroll, Rodriguez, & Nuwayhid, 2004), or have less social support in general (Jeanjot et al., 2008). Other researchers, however, have deemed perpetrator characteristics more significant than maternal demographics in predicting IPV during pregnancy, including instances in which the father did not want the pregnancy (Chu et al., 2010).
Sociostructural Risk Factors. The literature has identified several sociostructural risk factors associated with pregnancy and IPV. These include physical vulnerability on the part of the pregnant woman (Crawford, 2007; E. E. Saunders, 2000), stress 0acoby, Gorenflo, Wunderlich, & Eyler, 1999), and the aggressive mindset of the perpetrator (Cavanaugh & Genes, 2005). As with nonpregnant victims, a lack of or limited familial support systems is contributory as well 0asinski, 2004; Jeanjot et al., 2008; Sagrestano et al., 2004). Unique to pregnant women is that their dependency on the abuser for financial support may be increased by the anticipated support needed for the child as well as for themselves, which is believed to exacerbate the problem (Crawford, 2007; E. E. Saunders, 2000).
Risk Factors for Perpetrating IPV during Pregnancy. Fewer studies have examined the risk of IPV perpetration during pregnancy. Some have found that financial stress related to the pregnancy is a risk factor for perpetrating IPV, particularly among low-income adolescents (Brewer & Paulsen, 1999; Jacoby et al., 1999; Li, Kirby, Sigler, & Hwang, 2006; Rosen, 2004). Another study suggested that anger on the part of the perpetrator because of an unplanned pregnancy is associated with increased IPV during pregnancy (Gazmararian et al., 1996). A separate study purports the idea that a pregnant woman's focus on the arrival of her unborn child provokes jealousy in the perpetrator, causing him or her to become physically violent (Brewer & Paulsen, 1999).
Health- and Pregnancy-related Outcomes
According to the literature, IPV is associated with serious adverse health- and pregnancy-related outcomes for both the mother and the unborn child, including premature birth (Mezey & Bewley, 1997), low infant birth weight (Huth-Bocks, Levendosky, & Bogat, 2002; Parker, McFarlane, & Soeken, 1994), fetal injury, and fetal death (Mezey & Bewley, 1997; Newberger et al., 1992). The adverse outcomes for the mother are wide-ranging and include general poor health, frequent kidney infections, high blood pressure, urinary-tract infections, and sexually transmitted diseases (Rachana, Suraiya, Hisham, Abdulaziz, & Hai, 2002). In addition, women who experience IPV during pregnancy reportedly also enter prenatal care later (Huth-Bocks et al., 2002) and have insufficient weight gain (Shadigian & Bauer, 2004); more health problems during pregnancy (Chambliss, 2008; Silverman et al., 2006); and increased likelihood of premature labor due to placenta abruptions (Huth-Bocks et al., 2002), miscarriage (Mezey & Bewley, 1997), and maternal death (Chang, Berg, Saltzman, & Herndon, 2005). The literature has also reported that IPV during pregnancy leads to greater use of health care, with treatment of injuries, intensive care for the infant, increased number of emergency room visits, and increased hospitalization causing increased costs (Huth-Bocks et al., 2002).
The psychological effects of IPV experienced by pregnant women are similar to those experienced by nonpregnant IPV victims. IPV is linked to mental health complexities such as anxiety disorders, posttraumatic stress disorder, depression, low self-esteem, negative self-image, and fear of intimacy (Bergman & Brismar, 1991; Escriba-Aguir, Ruiz-Perez, & Saurel-Cubizolles, 2007; Murphy & Ouimet, 2008; Naumarm, Langford, Torres, Campbell, & Glass, 1999; Phelan, 2007). Other associated complications include prenatal substance abuse (NCADV, 2006) and suicide (Shadigian & Bauer, 2005). In a study examining IPV and women's depressive symptoms before and during pregnancy, higher levels of depressive symptoms were found among women who endured any level of physical or sexual coercion with intimate partners before or during pregnancy compared with women who did not experience such treatment (Martin, Li, & Casanueva, 2006). Martin et al. (2003) found that among substance-using pregnant women, those who experienced IPV had a greater number of substance disorder symptoms than did those who did not experience IPV. During pregnancy, the links between these women's experiences of IPV and their use of substances became stronger.
Effective intervention methods for pregnant women experiencing IPV have been discussed widely in the literature and include identifying IPV through screening, assessing for health and safety, identifying support systems, and examining the contextual effects of IPV on work and employment.
Identifying IPV through Screening. Gazmararian et al. (2000) suggested that effective intervention for IPV during pregnancy requires enhanced screening by primary care physicians, obstetricians and gynecologists, and nurses. The recommendation of the ACOG (2009) and the CDC (2007) is that all health-care providers routinely screen all patients for violence at regular intervals: during routine annual examinations, during preconceptual visits, once per trimester for pregnant women, and during postpartum examinations. Research has established that among all professionals, social workers are noted to be the most frequently contacted by battered women regarding all forms of IPV--physical, emotional, and sexual coercion (Hamilton & Coates, 1993). Thus, it is important that routine screening be expanded to nonmedical settings wherein social workers have contact with clients, especially those who are pregnant.
According to guidelines set by Futures Without Violence (FWV, 2004), the way that individuals are asked about IPV is extremely important. The literature explains that it must be done in a setting that is safe and where the individual is alone (FWV, 2004; McFarlane, Parker, & Cross, 2001; Shadigian & Bauer, 2004). This eliminates the risk of a potential perpetrator being present during the session.
It is the general consensus that effective screening must ask about all forms of IPV, including physical, psychological, and sexual IPV (ACOG, 1995; CDC, 2007; Shadigian & Bauer, 2004). Researchers have concluded that the questions used to ask about IPV must also be carefully considered (ACOG, 1995; American College of Nurse-Midwives, 2002; CDC, 2007; FWV, 2004). Stating framing questions and using direct questions can be an effective approach to IPV screening (Rodriguez et al., 1999; Shadigian & Bauer, 2004). In addition, rather than asking whether the individual has or is experiencing domestic violence or abuse, examples of behaviors should be provided that describe acts of IPV. Because language has been identified as a barrier to screening, researchers have suggested that questions should be available in a person's primary language and should be age and developmentally appropriate; when necessary, professional interpreters should assist in the screening process (FWV, 2004; Rodriguez et al., 1999). Showing diagrams of the body can be another effective screening tactic. Victims can point to specific areas on the body that have been direct targets of abuse (CDC, 2007; Soeken, McFarlane, Parker, & Lominack, 1998). Overall, screening for IPV should be implemented in a culturally competent manner (Rodriguez, et al., 1999).
Several screening tools for IPV are discussed in the literature. Those used most widely with women include the Hurt, Insult, Threatened with Harm, and Screamed At Scale (Sherin, Sinacore, Li, Zitter, & Shakil, 1998), the Abuse Assessment Screen developed by the Nursing Research Consortium in 1991 (McFarlane & Parker, 1994; McFarlane, Parker, Soeken, & Bullock, 1992; Parker & McFarlane, 1991), the Woman Abuse Screening Tool (Brown, Lent, Brett, Sas, & Pederson, 1996), and the Domestic Violence Initiative Screen (Webster, Stratigos, & Grimes, 1998). In some instances, expanded or abbreviated versions of these tools are used. Research, however, has suggested that these or any newly devised assessment or screening tools be enhanced to include clear definitions of IPV, questions that encompass linguistic and cultural sensitivity, and disclaimers to assure confidentiality (Crawford, 2007; Gunter, 2007; Lindhorst, Meyers, & Casey, 2008; Murphy & Ouimet, 2008). An ancillary component of universal screening should be a review of medical histories, specifically looking at past or present medical visits for injuries, repeated visits, and mental health disorders. If any of these are present, screening for IPV should be executed (CDC, 2007).
Assessing Health and Safety. On the basis of recommendations in the literature, assessing the health and safety of the IPV survivor is a crucial aspect of the intervention process. Once IPV is identified, appropriate intervention strategies can be used. It is critical that social workers be aware of the options available to assist survivors, be familiar with relevant community resources related to domestic violence, and be able provide survivors with accurate information and assistance in accessing services. The literature has recommended that the health and safety of the survivor be immediately assessed (CDC, 2007; Danis, 2003; FWV, 2004; Shadigian & Bauer, 2004). To evaluate the health of the survivor, questions can be asked about her physical and mental health. On the basis of her responses, the social worker or another professional can assist the survivor in obtaining medical treatment for injuries sustained as a result of IPV (Escriba-Aguir et al., 2007). For pregnant women, this might include an additional referral to a high-risk pregnancy physician who has specialized training in fetal and maternal complications associated with IPV.
A critical component of effective intervention highlighted in the literature is maintenance of the safety of IPV survivors, and, therefore, social workers should assist with devising personalized safety plans for both planned and emergency exit strategies (Danis, 2003). It is recommended that the social worker collaborate with a trained domestic violence specialist to develop a comprehensive safety plan. Safety plans vary on the basis of specific individual needs and circumstances and must be carefully considered (Danis, 2003; FWV, 2004). Safety plans should be carefully discussed with the survivor, and a range of options should be presented, including contacting authorities, obtaining protective orders, and accessing emergency housing (for example, battered women's shelters) or other safeguarded facilities (FWV, 2004; NCADV, 1999). Even if imminent danger is not present, social workers should heavily rely on collaboration with other agencies in the community to provide client referrals. In assisting survivors, social workers are encouraged to partner with local domestic violence programs, where counselors are specifically educated and trained in IPV protocols (FWV, 2004). In some hospital settings, there are individuals already trained specifically to address IPV (Tower, 2003).
LIMITATIONS AND FURTHER RESEARCH
The recommendations provided in this review must be considered within the context of a number of limitations. First, this article provides a review of the literature, but some important articles or reports might not have been identified because of the choice of search terms. Second, although general recommendations can be provided to better address IPV and pregnancy, many of these must be tailored to the needs of specific populations on the basis of characteristics such as ethnicity, immigration status, religion, and culture. These demographic characteristics are salient in both assessing IPV and developing appropriate intervention and prevention strategies. Further research is needed to better understand the occurrence of IPV in pregnancy so as to provide more contextual information that can help shape intervention efforts for different groups. In addition this review concentrated only on identifying and responding to IPV. Further research should explore the role of social workers in prevention of IPV during pregnancy and in policy advocacy.
The research findings on the widespread occurrence of IPV during pregnancy and its consequences are alarming. It is clear that this problem is of epidemic proportions and requires health-care professionals, including social workers, to be actively involved with the identification, assessment, intervention, and prevention of IPV. Pregnancy marks a unique opportunity for the social work profession to position itself to have a major impact in these areas. A review of the best practices for social workers that we identified are presented here:
* Social workers should be trained to identify and assess for IPV in all settings, using multiple sources of information. For those in contact with pregnant women, this should be especially emphasized, in conjunction with recognizing risk factors.
* Social workers can work with health-care personnel, training them to effectively use screening tools.
* All clients identified as experiencing IPV should be assessed for health and safety and be connected with appropriate supports.
* Social workers should address IPV in a culturally competent manner.
* Confidentiality and safety should be paramount for social workers engaging with IPV survivors.
* Social workers should work collaboratively with organizations, especially IPV-specific agencies, to effectively respond to victims of IPV.
* Social workers should provide appropriate medical and legal referrals for victims.
* Educating victims, family members, and the community on IPV prevention--generally and during pregnancy--should be a part of a social worker's mission.
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Original manuscript received May 13, 2011
Final revision received July 19, 2011
Accepted August 11, 2011
Advance Access Publication July 9, 2012
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Sarah McMahon, PhD, is assistant professor, Graduate School of Social Work, and associate director, Center on Violence Against Women and Children, and D'edra Y. Armstrong, MSW, is a research associate, Center on Violence Against Women and Children, Rutgers, The State
University of New Jersey, New Brunswick. Address correspondence to Sarah McMahon, Graduate School of Social Work, Rutgers, The State University of New Jersey, 536 George Street, New Brunswick, NJ 07016; e-mail: firstname.lastname@example.org, edu.
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