ACOG: Routinely Screen for Intimate Partner Violence

Laurie Barclay, MD

January 23, 2012

January 23, 2012 — Obstetricians and gynecologists should routinely and periodically screen all women for intimate partner violence (IPV), according to an American College of Obstetricians and Gynecologists (ACOG) Committee Opinion published in the February issue of Obstetrics & Gynecology. Screening for this significant, yet preventable, public health problem should also take place during prenatal visits, and physicians should offer support, referral, and resources, as needed, to women in abusive situations.

IPV involves control of a partner through a destructive pattern of abuse and coercion, including physical battery, psychological abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and reproductive coercion. IPV may affect heterosexual and same-sex couples of any age, sex, societal or financial level, religion, race, ethnicity, or educational achievement.

In addition to physical injuries, presentations of IPV may include chronic headaches, chronic pelvic pain, unintended pregnancy, irritable bowel syndrome, and recurrent vaginal infections.

In the United States, about 25% of women have experienced physical and/or sexual assault by a current or former partner, but the true prevalence of IPV is unknown because it includes other forms of abuse and because victims fear disclosure.

"Women of all ages experience [IPV], but it is most prevalent among reproductive-age women," Maureen G. Phipps, MD, chair of ACOG's Committee on Health Care for Underserved Women, said in a news release. "Nearly 324,000 pregnant women are abused by their partners each year in the US.... Sadly, one of the leading causes of maternal mortality in this nation is homicide."

Other poor pregnancy outcomes linked to IPV include stillbirth, poor weight gain, infection, fetal injury, preterm delivery, and low birth weight. Among women of reproductive age, other complications may include gynecologic disorders, unintended pregnancy, and HIV and other sexually transmitted infections.

Women affected by IPV may also experience depression, anxiety, substance abuse, emotional trauma, permanent physical disability, chronic health problems, and even suicide or death from other causes.

ACOG Recommendations

"We have a prime opportunity to identify and help women who are being abused by incorporating this screening into our routine office visits with each and every patient," Dr. Phipps said.

Because of the nature of the patient–physician relationship, obstetricians and gynecologists are in a unique position to evaluate and offer management for women affected by IPV. During women's health visits for annual examinations, family planning, and pregnancy, there are many opportunities for intervention:

  • Screening at periodic intervals and counseling for IPV should be an integral part of women's preventive health visits, according to the US Department of Health and Human Services.

  • These screenings should also occur during obstetric care, at the first prenatal visit, at least once per trimester, and at the postpartum checkup.

  • Screening should take place in a private and safe setting with the woman alone, and not in the presence of her partner, friends, family, or caregiver.

  • When an interpreter is needed, this should be a professional, rather than someone associated with the patient.

  • Screening should begin with a framing statement indicating that screening is performed routinely, rather than because IPV is suspected. The patient should be reassured that the discussion is confidential and informed of specific disclosures required by state law. Most states do not mandate reporting of IPV at all, or only in certain circumstances. Physicians should familiarize themselves with the laws in their specific jurisdiction.

  • The routine medical history should incorporate IPV screening by including pertinent questions on intake forms.

  • When clinicians identify IPV, they should also provide ongoing support and discuss prevention, referral options, and other available community resources.

  • Restrooms, examination rooms, and other privately accessible areas should contain printed take-home resources including safety procedures, hotline numbers, and referral information. Posters and other educational materials should also be displayed in the office.

  • Staff training about IPV should be regularly offered.

Reproductive Coercion

To establish power and maintain control in a relationship, some partners use reproductive coercion instead of or in addition to physical or sexual violence. Examples of reproductive coercion include sabotaging contraception, refusal to use condoms, or even intentional exposure of the partner to HIV or other sexually transmitted disease.

Other ways to control pregnancy outcomes may include forcing a partner to continue an undesired pregnancy or to have an abortion, and forbidding the woman to be sterilized or to use reproductive health services.

"We need to start normalizing the conversation about abuse with all of our patients, much like we've done with HIV testing," Dr. Phipps said. "Many women will not admit to being abused, but bringing up the subject in a caring and straightforward manner over time may encourage them to eventually seek help."

In collaboration with Futures Without Violence, ACOG developed a patient education card explaining IPV and reproductive coercion. It is available in Spanish, as well as English, and targets both teenagers and adults.

Obstet Gynecol. 2012;119:412-417. Abstract

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