Intimate Partner Violence: Urgent Implications for Women's Health

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Intimate Partner Violence Urgent Implications
for Women's Health

• Nancy Glass, PhD, MPH, RN
• Co-Director, Center for Health Disparities
  Research
• Oregon Health Science University
  www.ohsu.edu/healthdisparities/

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Objectives

• Define intimate partner violence (IPV).
• Describe the overlap of forms of IPV.
• Describe the prevalence of this public health
  problem.
• Describe physical, psychosocial and pregnancy
  related effects of IPV.

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Objectives

• Discuss use of assessment tools in clinical
  practice.
• Identify local and national resources for women
  in abusive relationships.

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Definition Intimate Partner Violence

• Centers for Disease Control and Prevention (CDC)
  
• Physical and/or sexual violence (use of physical
  force) or threat of such violence or
  psychological/ emotional abuse and/or coercive
  tactics when there has been prior physical and/or
  sexual violence between persons who are spouses
  or non marital partners (dating,
  boyfriend-girfriend, same-sex) or former spouses
  or non marital partners (Saltzman et.al. 99)

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Definition Intimate Partner Violence

• Conceptualized as a risk factor for many health
  problems rather than a disease or syndrome or
  diagnosis.

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Intimate Partner Violence

• Population-based telephone survey (N8000 women)
  (Tjaden Thoennes, 1998)
• 25 of women reported lifetime physical and/or
  sexual assault by an intimate or ex-intimate
  partner
• Estimated 4.8 million women report
  physical/sexual violence from an intimate in the
  past year.
• 40 of assaults result in injuries
• 20 seek health care services related to the
  assault
• 10 of Oregon women report physical/sexual
  violence from an intimate in the past year
  (Oregon DHHS).

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Overlap between physical, sexual and emotional
abuse (N 889) (Campbell et. al. 02)
Sexual (N 243)
32 (3.6)
14 (1.6)
31 (3.5)
166 (18.7)
177 (19.9)
166 (18.7)
303 (34.0)
Emotional (N 677)
Physical (N 649)
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General Health Outcomes

• Serious health outcomes, last long after the
  violence has ended.
• Survivors of IPV report poorer overall health
  status, poorer quality of life, and functional
  status as compared to women who report never
  experiencing IPV (Glass 2001, Sullivan et al.,
  1999 Plichta, 1996).

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Health Effects - 5 Major Studies (controlled,
pop based or large HMO Campbell et. al. 02
Coker et.al.00 Leserman et.al.98 McCauley
et.al.95 Plichta 96)
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Health Effects - 5 Major Studies (controlled,
pop based or large HMO Campbell et. al. 02
Coker et.al.00 Leserman et.al.98 McCauley
et.al.95 Plichta 96)
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Mental Health Outcomes

• Depression and Post Traumatic Stress Disorder
  (PTSD) most commonly reported mental health
  outcome of IPV (Campbell, 2001 Glass, 2001
  Campbell et al., 1997 Campbell et al., 1995)
• 59.2 of injured women from a Level 1 Trauma
  Center reported symptoms of PTSD (up to 5 years
  after the injury) (Glass, 2001)
• Relationship between IPV and suicidiality
  (McCauley et al., 1995)

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Mental Health Outcomes

• Substance Use (ETOH, illegal drugs, prescription
  drugs). (Sharps et al., 2001)
• Women with depression and/or PTSD may use
  substances to calm, cope with all three PTSD
  specific symptoms clusters (intrusion, avoidance,
  and hyperarousal)
• Dangerous reciprocal relationship between
  violence re-victimization and substance use
  (Dansky et al., 1997)

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Health Care Utilization

• Examined relationship of IPV and health care
  utilization in population and clinical studies
  has revealed poorer overall physical and mental
  health, higher incidence of injuries, increase
  consumption of health care resources
  (hospitalization, health visits, prescriptions)
  (McCauley et al., 1995 Campbell et al., 2001).
• Although there is an increased use of health
  care by abused women, only 20 are correctly
  identified (Campbell et al., 2002)

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Prevalence Pregnancy-Related Violence

• IPV during pregnancy range from 0.9 to 20.1
  (Gazmararian et al., 1996)
• The majority of studies, the prevalence estimate
  has ranged from 4-8
• Wide range of prevalence estimates likely the
  results of a variety of measures, populations
  sampled and methodology

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Oregon Prevalence Pregnancy Related Violence

• Findings are based on the results of the 2000
  Oregon DHS Pregnancy Risk Assessment Monitoring
  System (PRAMS)
• Ongoing survey of women who have recently given
  birth.
• 2,100 new mothers participated in the
  representative sample

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Oregon Prevalence Pregnancy-Related Violence

• During your recent pregnancy did your husband or
  partner push, hit, slap, kick, choke or
  physically hurt you in any other way"
• 2.6 of respondents answered YES
• Additionally, 0.8 of respondents, reported that
  someone else had physically hurt them while they
  were pregnant (ex-partner, ex-boyfriend)
• 1,472 new mothers reported being physically hurt
  while pregnant in 2000

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Oregon Prevalence Pregnancy Related Violence

• In addition to violence during the pregnancy
• 3.8 of respondents reported being physically
  hurt by their husband or partner in the 12 months
  before they became pregnant
• Another, 1.6 of respondents, reporting being
  physically hurt by someone else in the 12 months
  before they became pregnant
• 2,339 new mothers reporting being physically hurt
  in the year prior to the pregnancy

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Pregnancy and Violence

• Public health perspective, an important question
  is risk patterns to develop prevention programs
  to reduce IPV during pregnancy
• Are pregnant women at a greater risk of
  physical/sexual violence by their male partners
  or ex-partners compared to women who are not
  pregnant?
• Studies using national probability samples (e.g.
  National Family Violence Survey, 1985 1992
  National Alcohol and Family Violence Survey
  National Survey of Families and Households, 1988)
  have indicated that pregnant women were no more
  likely to be victims of IPV than women who were
  not pregnant
• In one survey, National Survey of Families and
  Households, 1988, persistent violence was more
  likely to occur among couples in which the male
  partner perceived that the pregnancy of his
  female partner occurred sooner than intended

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Risk Factors for Pregnancy-Related Violence

• Cumulative effect of multiple contextual and
  relationship factors and stressors, can impact
  parental perception of newborns, family
  environment, attitudes toward parenting, and
  levels of relationship discord (Fisher et al.,
  1998)

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Consequences of Pregnancy-Related Violence

• Consequences for both the unborn child and
  pregnant mother
• Late entry into prenatal care
• Low birth weight babies
• Premature labor
• Unhealthy maternal behaviors
• Fetal trauma
• Health issues for the mother

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Consequences of Pregnancy-Related Violence

• Late entry into prenatal care
• Healthy People 2010, 90 of pregnant women will
  begin prenatal care in first trimester
• Abused women are twice as likely to delay
  prenatal care until the 3rd trimester compared to
  women who were not abused (Goodwin et al., 2000)
• Late entry to prenatal care is a risk factor for
  pregnancy complications including low birth
  weight babies and premature labor

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Consequences of Pregnancy-Related Violence

• Low birth weight and Premature Labor
• Studies have been inconsistent in findings
  related to the association between IPV, premature
  labor and low birth weight infants (Curry
  Harvey, 1998 Cokkinides et al., 1999).
• In addition to IPV, low birth weight and
  premature labor may be associated with late entry
  into prenatal care, as well as unhealthy
  behaviors by the mother (e.g. smoking, poor
  nutrition)

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Consequences of Pregnancy-Related Violence

• Fetal Trauma (e.g miscarriage, spontaneous
  abortion)
• Experiencing IPV puts the unborn baby at risk
• Increased risk of miscarriage (Jacoby et al.,
  1999)
• Association between current IPV and at least one
  spontaneous abortion in the womans obstetric
  history (Jacoby et al., 1999)
• Increased risk of placental abruptions (Connolly
  et al., 1997)

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Consequences of Pregnancy-Related Violence

• Unhealthy Maternal Behaviors
• IPV indirect contribution to negative
  consequences for both unborn child and mother by
  increasing the risk for unhealthy maternal
  behaviors
• Abused women are more likely to smoke during
  pregnancy than women who are not abused
  (Cokkinides Coker, 1998)
• Prenatal patients (n2000), victims of IPV were
  more likely to smoke, drink and use drugs than
  women who were not abused (Martin et al., 1996)
• IPV victims were more likely to be in the most
  severe substance abuse category during pregnancy
  than nonabused women (Martin et al., 1996)

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Consequences of Pregnancy-Related Violence

• Health Issues for Mothers
• Unhealthy diet, severe postpartum depression,
  lower self-esteem, breastfeeding difficulties,
  anemia and poor weight gain have all been
  associated with IPV and pregnancy (Bohn Holz,
  1996)

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Femicide

• Femicide, murder of women
• 7th leading cause of premature death for women in
  US
• 2 cause of death - African-American women aged
  15-34
• 40-50 of US femicides by an intimate partner or
  ex-intimate partner (SHR analyses misclassifies
  many Langford, 98)
• 67-80 of intimate partner femicides were
  previously battered by their murderer

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Pregnancy and Femicide

• Femicide
• Femicide accounted for 25 of the injury deaths
  of pregnant women in NY City (Dannenberg et al.,
  1995)
• 13 of pregnancy related deaths were femicides in
  NC (Parsons Harper, 1999)
• 11 city study on intimate partner femicide,
  victims of femicide or attempted femicide were
  more likely to have been abused during pregnancy
  by the perpetrator than the comparison group of
  abuse women (McFarlane et al., 1999).
• Study found a 3 fold increased risk of femicide,
  if the woman was abused during pregnancy

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Pregnancy and Femicide

• Femicide
• Pregnancy in and of itself is NOT a risk factor
  for femicide
• Abuse during pregnancy is one of several risk
  factors for femicide/attempted femicide

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Femicide

• Femicide
• Important to note other significant risk factors
• Previous threats to kill her
• Partner/ex-partner unemployed and not looking for
  work
• Partner/ex-partner is not the biological parent
  of a child living in the home
• Woman is leaving the relationship and
  partner/ex-partner is controlling
• Partner/ex-partner owns a gun

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Kerry Repp Act-Oregon

• Focus on women as victim of violence during
  pregnancy
• Raise awareness of pregnancy as a dangerous time
  for some abused women
• Training for health care professionals, coroners,
  law enforcement, judges related to lethality and
  pregnancy

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Kerry Repp Act-Oregon

• We need to know if femicide is the leading cause
  of maternal mortality in Oregon
• Multidisciplinary Fatality Review System
• State and County levels
• Surveillance system of femicides in Oregon
• Develop prevention and intervention strategies

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Effects of IPV on Children

• Anxiety reactions and post-traumatic stress
  symptoms, e.g., irritability, agitation, trouble
  concentrating, exaggerated startle response,
  intrusive, unwanted memories
• School problems, e.g., declining grades,
  behavioral problems, truancy, suspensions,
  expulsions
• More physical health problem than general
  population.
• Worries about their mothers actual (e.g.,
  battering) and potential (e.g., smoking,
  pregnancy) health hazards
• Later, higher levels of violent behavior and
  arrests in children who have themselves been
  abused or neglected

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Missed Opportunities

• Few women report being asked about IPV at their
  health care visit (Glass et al., 2001)
• 41 of women murdered by intimate or ex-intimate
  partner were seen at a health care agency for an
  injury or mental health issue in the year prior
  to murder (Sharps et al., 2001)
• 20 of perpetrators of partner homicide were seen
  by a physician or mental health provider in year
  prior to murder (Sharps et al., 2001)

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Public Health Problem
Health Policy Screening
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Screening literature evidence insufficient

• Ramsey et al., British Medical Journal, 2002
• MacMillan Wathen, Canadian Task Force on
  Preventive Health Care, JAMA 2003
• Anglin Sachs., Acad Emerg Med, 2003
• Nelson et al., US Preventive Service Task Force,
  Annals Int Med., 2004

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• Sometimes clinical judgement trumps Cochrane.
  Sometimes humanity trumps evidence. Or perhaps
  the type of evidence we demand for this kind of
  healing should be different from what we demand
  for the efficacy of anticoagulation in atrial
  fibrillation.
• Lachs, Ann Intern Med 2004 p. 400

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Who to screen?

• EVERYONE! (Routine, Universal Screening)
• Only 56 of women presenting to the ED because of
  intimate partner violence had an injury related
  diagnosis

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How to Screen for IPV

• Display visual information
• How far does someone have to go in your setting
  before they know it is OK to talk about IPV?
• Ask in private
• Strategies to remove others from room prior to
  asking
• Make it a safe process
• Be nonjudgemental

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What to ask?

• Keep it simple!
• How you ask more important than what you ask!
• Have you been injured by a partner or ex-partner
  in the past year?
• Is there anyone making you feel unsafe?
• Has anyone made you have sex against your will?

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Abuse Assessment Screen
1. Have you ever been emotionally or physically
abused by your partner or someone important to
you? 2. Within the last year, have you been hit,
slapped, kicked, pushed or shoved, or otherwise
physically hurt by your partner or ex-partner?
If YES, by whom Number of times 3. Does
your partner ever force you into sex? 4. Are you
afraid of your partner or ex-partner? Heltin
McFarlane, 1986 Mark the area of any injury on
body map.
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Does Screening Identify Women at Risk?

• Women with a positive partner violence screen are
  9 times more likely (28 vs. 2) to experience
  physical violence in the next three months
  (Koziol-McLain, 1999).

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Document

• Use her words
• Name of perpetrator
• History of abuse
• Body Map, Photographs
• Danger Assessment (Lethality, Suicide,
  Depression)
• Interventions (Safety Plan)
• Referrals (Hotline, Shelter, Legal, Police)

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Assess Safety

• Escalating violence (lethality)
• Use or threat of weapon (gun, knife)
• Lack of support and isolation
• Recent separation from partner
• Risk to children
• Depression
• Risk for suicide

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Danger Assessment (Campbell, 2004)
http//www.son.jhmi.edu

• Developed in 1985 to increase battered womens
  ability to take care of themselves (Self Care
  Agency Orem 81, 92)
• Interactive, uses calendar - aids recall plus
  women come to own conclusions - more persuasive
  in adult learner/ strong woman/ survivor model
• Intended as lethality risk instrument versus
  reassault (e.g. SARA, K-SID) - risk factors may
  overlap but not exactly the same

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Danger Assessment

• 20 items yes/no plus calendar
• Shows pattern - frequency severity of past year
• Aids recall
• Summative, no cutoff
• 10 samples of 2251 battered women
• Internal consistency .60-.86 test-retest
  .89-.94
• Construct validity convergent w/CTS ISA (r
  .55-.75) discriminant group

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NATIONAL DOMESTIC VIOLENCE HOTLINE[phone]-SAFE
(7233)Family Violence Prevention
Fundwww.endabuse.org