Friday, December 3, 2010

Violence in Midwifery Part I: Intimate Partner Violence

Posted by Katy
Midwives deal with violence on a regular basis. Whether its violence experienced by the women we serve, violence within systems of health care, violence against women by providers, or violence within the community of midwives, violence should be looked at continuously in an attempt to understand it, cope with it, and curb it.

I’ve been seeing a patient in antepartum clinic that has a very interesting story suggestive of intimate partner violence (IPV). IPV is both affected by pregnancy and affects the course and outcomes of pregnancy. While the statistics of prevalence are fairly unknown, about 14% of pregnant women in the US experience IPV. IPV in pregnancy is associated with low weight gain, substance abuse, premature labor and birth, persistent STIs, anemia, vaginal bleeding, and complications associated with physical trauma. IPV is an important and relevant topic for midwives to be familiar with in order to best care for women. Intimate partner violence is challenging to fit into the process of diagnosis and management which makes midwives (and all providers) shirk away from the issue rather than dealing with it appropriately. This case study served as an important opportunity for me to become more competent in screening for and supporting women experiencing IPV.

This woman, let’s call her Josefina, came to the inner city hospital clinic where I’m doing clinicals for prenatal care. The first time I saw her she had bruises on her face that she said were from play fighting with her partner. She had been testing positive for chlamydia since the beginning of her pregnancy and had already been treated once. She said that her partner had not been treated and that they were still having sex without condoms, despite previous counseling on the importance of using condoms or abstinence to prevent reinfection. She withdrew with questioning about her social situation or the sexual relationship with her partner, and would not answer questions.
The next time I saw Josefina, she had been to the high-risk clinic to follow-up an abnormal ultrasound and had been seen by the social worker, who charted that she did not need follow-up. She had missed several appointments and had another positive chlamydia test before she saw me. She again denied intimate partner violence on the abuse assessment we used. Her partner still had not been treated and they had still been having sex without condoms. I was supposed to see Josefina again last week, but she did not come for her appointment. In many ways, Josefina's case is a classic "presentation" of IPV: physical signs of injury, low weight gain, persistent STI, poor compliance with appointments, and low familial support. It is difficult to know whether or not she is experiencing IPV given her unresponsiveness to questions and her denial of it. Regardless of her disclosure to me and the rest of the health care team regarding IPV, she is making important decisions for herself and the baby and one of the "interventions" we can offer is our support of her autonomy and choice.

I want to bring up two papers that discuss IPV in pregnancy. The first was a study conducted by Patricia Hindin concerning the way CNMs screen for IPV. Her study was qualitative and looked at interviews of 8 CNMs. The study found that while all of the midwives agreed that screening for intimate partner violence was an important component of prenatal care, screening practices were inconsistent. ACNM and ACOG recommends universal screening for IPV in every trimester, but providers tend to screen only patients that they deem at risk, despite recognizing that IPV occurs in women of every demographic. Midwives described barriers to screening including discomfort with the subject, a lack of knowledge concerning the appropriate plan of care, and fear of offending patients.

The second paper is a synthesis of evidence into a practice guideline for midwives written by Lisa Espinosa and Kathryn Osborne. This paper took the public health approach for “management” of IPV which includes interventions on the levels of primary, secondary, and tertiary prevention. Primary prevention focuses on the avoidance of intimate partner violence before it occurs through population-level methods of violence prevention including legal policy, societal change, and supporting autonomy and equality of women.
Secondary prevention seeks to reduce harm by detecting violence early. Women who were surveyed concerning screening for IPV stated that they appreciated being asked about domestic violence, even if they are unaffected by it, as it demonstrates the quality of care they are receiving. According to the CDC, asking directly about intimate partner violence gives the woman confidence that the midwife knows how to support them if they are in a situation of intimate partner violence. Screening should be done at least every trimester as patterns of violence change during pregnancy and it may take several visits before a woman feels comfortable reporting violence. If IPV is suspected or identified, the focus of counseling should be to support the woman in making informed choices and to ensure that the spectrum of available choices is wide. Midwives can further contribute to making choices available by supporting organizations that offer intervention services.

Tertiary prevention focuses on supporting women who are known to be experiencing intimate partner violence. Women experiencing intimate partner violence should know signs of lethality and have a safety plan. The woman should be provided with resources including hotline number to call and information of local shelters. She should be counseled to pack a safety bag that includes anything she might need including money and important documents that can either be taken quickly if the woman needs to leave the house, or can be left with someone she trusts. Signs of lethality include increasing severity or frequency of abuse, use or availability of weapons, sexual abuse, and abuse of children. Referrals should be made for every woman that is suspected to be experiencing IPV to hotlines, shelters, counseling, and community organizations supporting women experiencing IPV. Care should be taken to ensure that the information given will not put the woman at greater risk of violence by always respecting the woman’s choice of what she wants to do and by encouraging memory of important phone numbers or web addresses if safety is a concern. Midwives also have a role in the legal process of protecting women and prosecuting perpetrators of violence. Proper documentation is important to serve as evidence for women seeking protection. If the woman wants, physical injuries can be photographed, a body map can be used to describe specific injuries, and accounts of abuse should always be documented accurately and completely.

Managing situations of intimate partner violence is challenging for most midwives. Adequate preparation helps midwives to be competent and feel confident in screening, counseling women, and making referrals. I hope that my personal education on how to deal with IPV will make my screening more effective and will aid the fostering of trusting relationships with my patients, but most of all I hope that it allows me to make space to care for women experiencing IPV to support them in their holistic health.

Abuse Assessment Screen from the CDC
1.      In the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? (If yes, by whom? Number of times? Nature of injury?)
2.      Since you’ve been pregnant have you been hit, slapped, kicked, or otherwise physically hurt by someone?
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?

Espinosa, L., & Osborne, K. (2002, Sept/Oct). Domestic Violence During Pregnancy: Implications for Practice. Journal of Midwifery & Women's Health, 47(5), 305-318.
Hindin, P. K. (2006, May/June). Intimate Partner Violence Screening Practices of Certified Nurse-Midwives. Journal of Midwifery & Women's Health, 51(3), 216-221.

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