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Battering in pregnancy: An assessment of two screening methods
OBSTETRICS& GYNECOLOGY
Volume 85
March 1995
Number 3
Battering in Pregnancy: An Assessment of Two Screening Methods LYNN B. NORTON, MD, JEFFREY F. PEIPERT, MD, MPH, SALLY ZIERLER, DrPH, BETHANY LIMA, MSW, AND LUCY HUME, BA Objective: To compare two different screening techniques for identifying women with a history of domestic violence or battering in the current pregnancy. Methods: The five-question Abuse Assessment Screen was incorporated into routine social service interviews and applied prospectively to all registrants for routine prenatal care at Women & Infants' Hospital during an initial social service evaluation from September 7 through October 29, 1993. This group (N = 143) was compared to a historical control group of all new registrants from July 12 through September 3, 1993 (N = 191) who had routine interviews by social services. Demographic and medical data were compared, as well as the specific information addressed by the screen, including history of domestic violence, physical or sexual violence within the last year, violence during the current pregnancy, recent sexual abuse, and fear of partner. Results: The median age of the study population was 23 years old, 50% were white, 63% were single, and 42% had no insurance. There was a higher detection of violence in all categories using the Abuse Assessment Screen compared with the standard interview--any history: 41 versus 14% (relative risk [RR] 3.0, 95% confidence interval [CI] 2.0-4.5); recent history: 15 versus 3% (RR 5.6, CI 2.2-14.5); during pregnancy: 10 versus 1% (RR 9.3, CI 2.2-40.5); recent sexual From the Department of Obstetrics and Gynecology, Women & Infants" Hospital, Providence; and the Department of Community Health, Brown University School of Medicine, Providence, Rhode Island.
VOL. 85, NO. 3, MARCH 1995
abuse: 4 versus 0% (P = .006); and fear of abuser: 6 versus 3% (RR 1.8, CI 0.6-5.0). Conclusion: Use of a structured screen improves detection rates of battering both before and during pregnancy, enabling clinicians to have a greater opportunity to intervene.
(Obstet Gynecol 1995;85:321-5)
Domestic violence is a major health concern for women in the United States. Violence does not stop during pregnancy, with an estimated 7-17% of all screened women admitting to abuse during the current pregnancy. 1-7 Current ability to address the problems of domestic violence depends on our ability to screen effectively. The Abuse Assessment Screen, developed by the Nursing Research Consortium on Violence and Abuse, uses five questions to assess remote and recent history of violence, both sexual and physical, as well as abuse during pregnancy and fear of the abuser. This screen has been shown to correlate with more elaborate questionnaires, such as the Conflict Tactics Scale and the Index of Spouse Abuse. 3 We compared a social service interview that incorporated the five questions from the Abuse Assessment
0029-7844/95/$9.50 321 0029-7844(94)00429-H
Table 1, Questions Included in the Abuse Assessment Screen 1) Have yon ever been emotionally or physically abused by your partner or someone important to you? Yes No 2) Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Yes No If yes, by whom? (circle all that apply) Husband Ex-husband Boyfriend Stranger Other No. of t i m e s :
Multiple
3) Since you've been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Yes No If yes, by whom? (circle all that apply) Husband Ex-husband Boyfriend Stranger Other Multiple No. of times: _ _ Mark area of injury on the body map. (body map included) Score the most severe incident to the following scale: 1 = Threats of abuse, including use of a weapon 2 = Slapping, pushing; no injuries and/or lasting pain 3 = Punching, kicking, bruises, cuts, and/or continuing pain 4 = Beaten up, severe contusions, bums, broken bones 5 = Head, internal, and/or permanent injury 6 = Use of weapon, wound from weapon 4) Within the past year, has anyone forced you to have sexual activities? Yes No If yes, by whom? (circle all that apply) Husband Ex-husband Boyfriend Stranger Other Multiple No. of times:
8-week interval b e t w e e n July 12 a n d September 3, 1993; controls had r o u t i n e social service interviews w i t h o u t the A b u s e A s s e s s m e n t Screen. These i n t e r v i e w s were also c o n d u c t e d b y trained social w o r k e r s a n d covered social history, i n c l u d i n g domestic violence, health behaviors, a n d psychologic risks. The results of this baseline risk assessment were d o c u m e n t e d o n s t a n d a r d forms in the m e d i c a l record. If assessments or screens for domestic violence were positive, the social w o r k e r placed a "consult note" in the chart. The s t a n d a r d risk assessment forms a n d the social service consult notes were reviewed. The results of these evaluations, i n c l u d ing the extent of b a t t e r i n g in the c u r r e n t p r e g n a n c y , history of domestic violence, a n d history of sexual abuse, were recorded o n specially d e s i g n e d extraction forms. For both groups, i n t e r v i e w s were c o n d u c t e d in a private setting separate from the partner. A translator was present, if necessary. Low-risk obstetric patients were chosen for the e v a l u a t i o n because they are assessed w i t h a s t a n d a r d social service evaluation. Alt h o u g h adolescents a n d w o m e n with high-risk pregnancies m a y be at a higher risk for abuse, these subjects were n o t i n c l u d e d because these g r o u p s did not have the same r o u t i n e social service risk assessment. Patients w h o did not have a social service i n t e r v i e w d u r i n g the
5) Are you afraid of your partner or anyone you listed above? Yes No Table 2, Characteristics of the Routine Social Work-
Screened Group and the Abuse Assessment Screen Group Screen to the r o u t i n e social service interviews performed for risk assessment of all low-risk prenatal patients. O u r hypothesis was that a structured questionnaire w o u l d i m p r o v e detection of a history of a b u s e a n d of abuse in the c u r r e n t p r e g n a n c y , c o m p a r e d with a r o u t i n e social service evaluation.
Materials and Methods At W o m e n & Infants' Hospital b e t w e e n September 7 a n d October 29, 1993, all n e w registrants for r o u t i n e p r e n a t a l care i n the low-risk obstetrics category were e v a l u a t e d prospectively with a social service i n t e r v i e w that incorporated the A b u s e A s s e s s m e n t Screen. This screen assesses remote a n d recent history of violence w i t h five s t r u c t u r e d a n d directed questions (Table 1). To identify sites of injury, the screen also i n c l u d e s a b o d y m a p i n c o n j u n c t i o n with the third question. Responses were recorded b y social w o r k e r s on specially d e s i g n e d data collection forms that contained the A b u s e Assessm e n t Screen. Results of this g r o u p were c o m p a r e d with those of a c o n t r o l g r o u p g a t h e r e d d u r i n g a n earlier, s i m i l a r
322
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Battering in Pregnancy
Race White Black Hispanic Other Insurance Public Private None Unemployed Marital status Single Married Other Alcohol use Smoking Drug history Current drug use Unplanned pregnancy Age (y) (mean) Parity (mean)
Routine screen (N= 191)
Abuse Assessment Screen (N= 143)
100 (52.4%) 33 (17.3%) 42 (22.0%) 16 (8.3%)
69 (48.3%) 33 (23.1%) 30 (21.0%) 11 (7.6%)
96 (50.0%) 16 (8.4%) 79 (41.4%) 114 (59.7%)
72 (50.4%) 9 (6.3%) 62 (43.4%) 78 (54.6%)
115 (60.2%) 39 (20.4%) 37 (19.4%) 14 (7.3%) 56 (29.3%) 32 (18.1%) 11 (5.9%) 136 (71.2%)
94 (65.7%) 31 (21.7%) 18 (12.6%) 16 (11.2%) 48 (33.6%) 21 (17.4%) 7 (5.0%) 113 (79.0%) 23.5 1.0
24.6 1.2
All comparisons are not statistically significant. Data are presented as N (%) or mean.
Obstetrics & Gynecology
[ 50-
[ ] Standard Screen
[ ] Abuse Assessment Screen }
A
454035-
Figure 1. Detection rates of domestic violence with a routine social work interview compared to an interview incorporating the Abuse Assessment Screen.
.,
3025-
~" 2 0 151050-
History of Domestic Violence**
study period (less than 5% in each group) were also excluded because their data was unavailable. Approval for the study was obtained from the Women & Infants' Hospital Institutional Review Board before the initiation of the study. Because the addition of the five questions from the Abuse Assessment Screen to the routine social service interview was seen as an extension of clinical care, written, informed consent for each patient was not necessary. All data were entered into a computerized data base. Statistical analysis was performed using Statistical Analysis Software (SAS Institute, Cary, NC) and EpiInfo 5.0 (Centers for Disease Control Atlanta, GA). Analyses included ~ and Fisher exact test for categoric variables and unpaired t tests for continuous variables. Statistical significance was defined as P < .05. We estimated the relative effect of detection of domestic violence using the Abuse Assessment Screen compared with a routine interview. Relative risks (RRs) and 95% confidence intervals (CIs) provided these estimates. We also estimated associations between selected characteristics of the entire cohort of women evaluated by either method and the occurrence of partner violence in their lives. These associations are presented as RRs and 95% CIs. The sample size was determined by the number of low-risk obstetric patients presenting over two consecutive 8-week intervals. This number of approximately 150-160 per group provided a greater than 80% power to detect a 2.5-fold increased risk of detecting a history of battering with the Abuse Assessment Screen.
VOL. 85, NO. 3, MARCH 1995
Recent Abuse**
Battering in Pregnancy**
Sexual Abuse*
Afraid of
Partner
**P<0.0001, *P<0.01
Results In our study population (N = 334), the median age was 23 years old, approximately half were white (50.4%), and most were unemployed (57.5%), single (62.5%), and had public (50%) or no insurance (42%). In addition, the median parity of the population was 1.1, and most of the pregnancies were unplanned (74.6%). There were no significant differences in the demographic or reproductive characteristics between the Abuse Assessment Screen group (N = 143) and the routine social service interview group (N = 191) (Table 2). The Abuse Assessment Screen detected a higher rate of violence in each category when compared with the routine social service interview (Figure 1). Women were three times more likely to report any history of domestic violence when asked questions from the Abuse Assessment Screen relative to the routine interview (41 versus 14%; RR 3.0, CI 2.0-4.5). The Abuse Assessment Screen detected more violence in the last year (15 versus 3%; RR 5.6, CI 2.2-14.5), and during the current pregnancy (10 versus 1%; RR 9.3, CI 2.2-40.5). Table 3 lists variables associated with domestic violence during pregnancy and a history of domestic violence in the entire cohort of patients. Cigarette smoking, alcohol use, history of drug use, and lack of involvement with the father of the infant were associated with any history of domestic violence. History of drug use and lack of involvement with the father of the infant were associated with abuse in the last year. Battering during pregnancy was associated with lack of
Norton et
al
Battering in Pregnancy 323
T a b l e 3. Characteristics Associated With a History of
Domestic Violence and Battering in Current Pregnancy Any history of domestic violence RR
Public or no insurance (vs private) Lack of involvement of father of infant Smoking Alcohol use History of drug use
95% CI
Abuse in previous 12 mo RR
95% CI
6.72 0.98-46.23 2.02 0.29-14.31 1.76 1.21-2.56
Abuse in current pregnancy RR
CI
*
3.44 1.58-Z49 3.16 1.14-8.72
1.84 1.29-2.63 1,62 0.77-3,41 1.72 0.66-4.49 1,94 1.31-2.90 1.58 0.63-3.98 1.65 0.49-5.54 2.04 1.38-3.02 2.93 1.31-6.58 1.61 0.53-4.85
RR = relative risk; CI = confidence interval.
*This cannot be calculated because there were no cases of abuse in pregnancy in the private insurance group.
involvement with the father of the infant. There was no significant difference in the m e a n estimated gestational age between abused and n o n a b u s e d w o m e n . H o w e v e r , 38% (six of 16) of w o m e n w h o were in an abusive relationship during the p r e g n a n c y registered later than 20 weeks' gestation, whereas 23% (72 of 318) of w o m e n w h o were not currently being abused registered after 20 weeks (P = .17).
Discussion The current ability to address the problems of domestic violence initially d e p e n d s on careful screening and identification. W o m e n w h o are being abused are often reluctant to admit to violence, in part because of shame, fear, and a belief that people will not u n d e r s t a n d or be able to help. One study 3 of prenatal patients f o u n d that only 8% of w o m e n filled out a form stating that they had been abused, but in that same g r o u p of w o m e n , 29% admitted to abuse w h e n questioned b y their prenatal care provider. Smith s f o u n d that detection rates i m p r o v e d w h e n more than one question pertaining to violence was asked during a single interview. In addition, increased detection has been noted with repeated questioning on multiple visits. 3 A l t h o u g h we assume our detection rate w o u l d increase with repeated interviews on multiple visits, this a p p r o a c h was not practical in this s t u d y because the social workers only performed repeated or follow-up interviews on patients with a positive screen for violence or with other social problems. Direct questioning seems to be an important tool. A s t u d y looking at trauma patients presenting to an
324
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Battering in Pregnancy
emergency r o o m f o u n d that before a screen w a s instituted for domestic violence, only 5.6% of injuries were attributed to battering, whereas after the screen was instituted, 30% were attributed to violence. Eight years later in the same institution, the screen w a s no longer used, and domestic violence was cited by only 7.7% of t r a u m a patients. 9 In our study, a higher rate of domestic violence was detected in all categories using the Abuse Assessment Screen. Possibilities for this finding include the specific focus on abuse as well as the use of several targeted questions d u r i n g the interview. Previous studies 1"s'6'9 have noted associations between battering and other social risk factors, such as substance abuse, emotional problems, and lack of social support. In our study, h a v i n g public insurance or no insurance was associated with abuse in the current pregnancy. Also in our study, lack of involvement with the father of the infant was associated with a history of domestic violence as well as more recent abuse. This finding m a y be a response to the battering episode, although no definitive conclusions can be m a d e because the temporal relationship cannot be determined. Smoking, alcohol use, and a history of d r u g use were more c o m m o n in abused w o m e n , but the associations were not significant because of the limited sample size. Strengths of the s t u d y include a prospective evaluation of the Abuse Assessment Screen and a historical control g r o u p comparable to the s t u d y population. It m a y be considered a limitation that information from the routine social service interview was determined b y a retrospective chart review. H o w e v e r , the social w o r k d e p a r t m e n t confirmed that all ascertained cases of domestic violence w o u l d be clearly stated in the medical record with plans for referral. Adolescents and patients followed in our high-risk obstetric clinic were not included in the study, and this m a y limit generalizability to these g r o u p s because they m a y be at high risk for battering in pregnancy. A final limitation is that interviews in both g r o u p s took place only once early in pregnancy, which m a y underestimate battering in pregnancy. McFarlane et al 3 f o u n d a 17% incidence of battering d u r i n g p r e g n a n c y with higher yields on questioning during each trimester. Theories for this include a greater willingness to disclose abuse once rapport with a provider has been established and the longer time frame for abusive incidents to occur. In our study, all positive screens were referred to social workers w h o offered resources, including counseling, shelter, and legal aid. In addition, social workers followed these patients d u r i n g p r e g n a n c y and at delivery to ensure that the patients continued to have access to services. The goal of this social w o r k intervention is to discharge the patient and her n e w b o r n to a safe and secure environment.
Obstetrics & Gynecology
O u r s t u d y s u p p o r t s t h e u s e of five s i m p l e s t r u c t u r e d q u e s t i o n s to i n c r e a s e d e t e c t i o n rates of d o m e s t i c violence. A l l h e a l t h care p r o v i d e r s s h o u l d b e t r a i n e d to p e r f o r m u n i v e r s a l s c r e e n i n g u s i n g a t a r g e t e d s c r e e n for d o m e s t i c v i o l e n c e i n all p r e n a t a l p a t i e n t s . C l i n i c i a n s d e t e c t i n g d o m e s t i c v i o l e n c e s h o u l d b e a w a r e of t h e r e s o u r c e s i n t h e i r area a n d b e p r e p a r e d to p r o v i d e t e l e p h o n e n u m b e r s a n d referrals to p a t i e n t s . By detecti n g m o r e cases of b a t t e r i n g d u r i n g p r e g n a n c y , c l i n i c i a n s h a v e m o r e o p p o r t u n i t y to i n t e r v e n e a n d p r o t e c t t w o lives f r o m a d a n g e r o u s a n d p o t e n t i a l l y fatal e n v i r o n ment.
References 1. Hillard PJ. Physical abuse in pregnancy. Obstet Gynecol 1985;66: 185--90. 2. HeRon AS, McFaflane J, Anderson E. Battered and pregnant: A prevalence study. Am J Public Health 1987;77:1337-9. 3. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy: Severity and frequency of injuries and associated entry into prenatal care. JAMA 1992;267:3176-8. 4. Bullock L, McFaflane J. The birthweight/battering connection. Am J Nurs 1989;89:1153-5. 5. Amaro H, Fried L, Cabral H, Zuckerman B. Violence during pregnancy and substance use. Am J Public Health 1990;80:575-9.
VOL. 85, NO. 3, MARCH 1995
6. Campbell J, Poland M, Waller J, Ager J. Correlates of battering during pregnancy. Res Nurs Health 1992;15:219-26. 7. Parker B, McFarlane J, Soeken K. Abuse during pregnancy: Effects on maternal complications and birth weight in adult and teenage women. Obstet Gynecol 1994;84:323-8. 8. Smith MD. The incidence and prevalence of woman abuse in Toronto. Violence Vict 1987;2:173-87. 9. McLeer S, Anwar R, Herman S, Maquiling K. Education is not enough: A systems failure in protecting battered women. Ann Emerg Med 1989;18:651-3.
Address reprint requests to:
Jeffrey F. Peipert, MD Department of Obstetrics and Gynecology Women & Infant's Hospital 101 Dudley Street Providence, RI 02905
ReceivedJuly 28, 1994. Received in revisedform November21, 1994. Accepted November29, 1994 Copyright © 1995 by The American College of Obstetricians and Gynecologists.
Norton et al
Battering in Pregnancy 325
Volume 85
March 1995
Number 3
Battering in Pregnancy: An Assessment of Two Screening Methods LYNN B. NORTON, MD, JEFFREY F. PEIPERT, MD, MPH, SALLY ZIERLER, DrPH, BETHANY LIMA, MSW, AND LUCY HUME, BA Objective: To compare two different screening techniques for identifying women with a history of domestic violence or battering in the current pregnancy. Methods: The five-question Abuse Assessment Screen was incorporated into routine social service interviews and applied prospectively to all registrants for routine prenatal care at Women & Infants' Hospital during an initial social service evaluation from September 7 through October 29, 1993. This group (N = 143) was compared to a historical control group of all new registrants from July 12 through September 3, 1993 (N = 191) who had routine interviews by social services. Demographic and medical data were compared, as well as the specific information addressed by the screen, including history of domestic violence, physical or sexual violence within the last year, violence during the current pregnancy, recent sexual abuse, and fear of partner. Results: The median age of the study population was 23 years old, 50% were white, 63% were single, and 42% had no insurance. There was a higher detection of violence in all categories using the Abuse Assessment Screen compared with the standard interview--any history: 41 versus 14% (relative risk [RR] 3.0, 95% confidence interval [CI] 2.0-4.5); recent history: 15 versus 3% (RR 5.6, CI 2.2-14.5); during pregnancy: 10 versus 1% (RR 9.3, CI 2.2-40.5); recent sexual From the Department of Obstetrics and Gynecology, Women & Infants" Hospital, Providence; and the Department of Community Health, Brown University School of Medicine, Providence, Rhode Island.
VOL. 85, NO. 3, MARCH 1995
abuse: 4 versus 0% (P = .006); and fear of abuser: 6 versus 3% (RR 1.8, CI 0.6-5.0). Conclusion: Use of a structured screen improves detection rates of battering both before and during pregnancy, enabling clinicians to have a greater opportunity to intervene.
(Obstet Gynecol 1995;85:321-5)
Domestic violence is a major health concern for women in the United States. Violence does not stop during pregnancy, with an estimated 7-17% of all screened women admitting to abuse during the current pregnancy. 1-7 Current ability to address the problems of domestic violence depends on our ability to screen effectively. The Abuse Assessment Screen, developed by the Nursing Research Consortium on Violence and Abuse, uses five questions to assess remote and recent history of violence, both sexual and physical, as well as abuse during pregnancy and fear of the abuser. This screen has been shown to correlate with more elaborate questionnaires, such as the Conflict Tactics Scale and the Index of Spouse Abuse. 3 We compared a social service interview that incorporated the five questions from the Abuse Assessment
0029-7844/95/$9.50 321 0029-7844(94)00429-H
Table 1, Questions Included in the Abuse Assessment Screen 1) Have yon ever been emotionally or physically abused by your partner or someone important to you? Yes No 2) Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Yes No If yes, by whom? (circle all that apply) Husband Ex-husband Boyfriend Stranger Other No. of t i m e s :
Multiple
3) Since you've been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Yes No If yes, by whom? (circle all that apply) Husband Ex-husband Boyfriend Stranger Other Multiple No. of times: _ _ Mark area of injury on the body map. (body map included) Score the most severe incident to the following scale: 1 = Threats of abuse, including use of a weapon 2 = Slapping, pushing; no injuries and/or lasting pain 3 = Punching, kicking, bruises, cuts, and/or continuing pain 4 = Beaten up, severe contusions, bums, broken bones 5 = Head, internal, and/or permanent injury 6 = Use of weapon, wound from weapon 4) Within the past year, has anyone forced you to have sexual activities? Yes No If yes, by whom? (circle all that apply) Husband Ex-husband Boyfriend Stranger Other Multiple No. of times:
8-week interval b e t w e e n July 12 a n d September 3, 1993; controls had r o u t i n e social service interviews w i t h o u t the A b u s e A s s e s s m e n t Screen. These i n t e r v i e w s were also c o n d u c t e d b y trained social w o r k e r s a n d covered social history, i n c l u d i n g domestic violence, health behaviors, a n d psychologic risks. The results of this baseline risk assessment were d o c u m e n t e d o n s t a n d a r d forms in the m e d i c a l record. If assessments or screens for domestic violence were positive, the social w o r k e r placed a "consult note" in the chart. The s t a n d a r d risk assessment forms a n d the social service consult notes were reviewed. The results of these evaluations, i n c l u d ing the extent of b a t t e r i n g in the c u r r e n t p r e g n a n c y , history of domestic violence, a n d history of sexual abuse, were recorded o n specially d e s i g n e d extraction forms. For both groups, i n t e r v i e w s were c o n d u c t e d in a private setting separate from the partner. A translator was present, if necessary. Low-risk obstetric patients were chosen for the e v a l u a t i o n because they are assessed w i t h a s t a n d a r d social service evaluation. Alt h o u g h adolescents a n d w o m e n with high-risk pregnancies m a y be at a higher risk for abuse, these subjects were n o t i n c l u d e d because these g r o u p s did not have the same r o u t i n e social service risk assessment. Patients w h o did not have a social service i n t e r v i e w d u r i n g the
5) Are you afraid of your partner or anyone you listed above? Yes No Table 2, Characteristics of the Routine Social Work-
Screened Group and the Abuse Assessment Screen Group Screen to the r o u t i n e social service interviews performed for risk assessment of all low-risk prenatal patients. O u r hypothesis was that a structured questionnaire w o u l d i m p r o v e detection of a history of a b u s e a n d of abuse in the c u r r e n t p r e g n a n c y , c o m p a r e d with a r o u t i n e social service evaluation.
Materials and Methods At W o m e n & Infants' Hospital b e t w e e n September 7 a n d October 29, 1993, all n e w registrants for r o u t i n e p r e n a t a l care i n the low-risk obstetrics category were e v a l u a t e d prospectively with a social service i n t e r v i e w that incorporated the A b u s e A s s e s s m e n t Screen. This screen assesses remote a n d recent history of violence w i t h five s t r u c t u r e d a n d directed questions (Table 1). To identify sites of injury, the screen also i n c l u d e s a b o d y m a p i n c o n j u n c t i o n with the third question. Responses were recorded b y social w o r k e r s on specially d e s i g n e d data collection forms that contained the A b u s e Assessm e n t Screen. Results of this g r o u p were c o m p a r e d with those of a c o n t r o l g r o u p g a t h e r e d d u r i n g a n earlier, s i m i l a r
322
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Battering in Pregnancy
Race White Black Hispanic Other Insurance Public Private None Unemployed Marital status Single Married Other Alcohol use Smoking Drug history Current drug use Unplanned pregnancy Age (y) (mean) Parity (mean)
Routine screen (N= 191)
Abuse Assessment Screen (N= 143)
100 (52.4%) 33 (17.3%) 42 (22.0%) 16 (8.3%)
69 (48.3%) 33 (23.1%) 30 (21.0%) 11 (7.6%)
96 (50.0%) 16 (8.4%) 79 (41.4%) 114 (59.7%)
72 (50.4%) 9 (6.3%) 62 (43.4%) 78 (54.6%)
115 (60.2%) 39 (20.4%) 37 (19.4%) 14 (7.3%) 56 (29.3%) 32 (18.1%) 11 (5.9%) 136 (71.2%)
94 (65.7%) 31 (21.7%) 18 (12.6%) 16 (11.2%) 48 (33.6%) 21 (17.4%) 7 (5.0%) 113 (79.0%) 23.5 1.0
24.6 1.2
All comparisons are not statistically significant. Data are presented as N (%) or mean.
Obstetrics & Gynecology
[ 50-
[ ] Standard Screen
[ ] Abuse Assessment Screen }
A
454035-
Figure 1. Detection rates of domestic violence with a routine social work interview compared to an interview incorporating the Abuse Assessment Screen.
.,
3025-
~" 2 0 151050-
History of Domestic Violence**
study period (less than 5% in each group) were also excluded because their data was unavailable. Approval for the study was obtained from the Women & Infants' Hospital Institutional Review Board before the initiation of the study. Because the addition of the five questions from the Abuse Assessment Screen to the routine social service interview was seen as an extension of clinical care, written, informed consent for each patient was not necessary. All data were entered into a computerized data base. Statistical analysis was performed using Statistical Analysis Software (SAS Institute, Cary, NC) and EpiInfo 5.0 (Centers for Disease Control Atlanta, GA). Analyses included ~ and Fisher exact test for categoric variables and unpaired t tests for continuous variables. Statistical significance was defined as P < .05. We estimated the relative effect of detection of domestic violence using the Abuse Assessment Screen compared with a routine interview. Relative risks (RRs) and 95% confidence intervals (CIs) provided these estimates. We also estimated associations between selected characteristics of the entire cohort of women evaluated by either method and the occurrence of partner violence in their lives. These associations are presented as RRs and 95% CIs. The sample size was determined by the number of low-risk obstetric patients presenting over two consecutive 8-week intervals. This number of approximately 150-160 per group provided a greater than 80% power to detect a 2.5-fold increased risk of detecting a history of battering with the Abuse Assessment Screen.
VOL. 85, NO. 3, MARCH 1995
Recent Abuse**
Battering in Pregnancy**
Sexual Abuse*
Afraid of
Partner
**P<0.0001, *P<0.01
Results In our study population (N = 334), the median age was 23 years old, approximately half were white (50.4%), and most were unemployed (57.5%), single (62.5%), and had public (50%) or no insurance (42%). In addition, the median parity of the population was 1.1, and most of the pregnancies were unplanned (74.6%). There were no significant differences in the demographic or reproductive characteristics between the Abuse Assessment Screen group (N = 143) and the routine social service interview group (N = 191) (Table 2). The Abuse Assessment Screen detected a higher rate of violence in each category when compared with the routine social service interview (Figure 1). Women were three times more likely to report any history of domestic violence when asked questions from the Abuse Assessment Screen relative to the routine interview (41 versus 14%; RR 3.0, CI 2.0-4.5). The Abuse Assessment Screen detected more violence in the last year (15 versus 3%; RR 5.6, CI 2.2-14.5), and during the current pregnancy (10 versus 1%; RR 9.3, CI 2.2-40.5). Table 3 lists variables associated with domestic violence during pregnancy and a history of domestic violence in the entire cohort of patients. Cigarette smoking, alcohol use, history of drug use, and lack of involvement with the father of the infant were associated with any history of domestic violence. History of drug use and lack of involvement with the father of the infant were associated with abuse in the last year. Battering during pregnancy was associated with lack of
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T a b l e 3. Characteristics Associated With a History of
Domestic Violence and Battering in Current Pregnancy Any history of domestic violence RR
Public or no insurance (vs private) Lack of involvement of father of infant Smoking Alcohol use History of drug use
95% CI
Abuse in previous 12 mo RR
95% CI
6.72 0.98-46.23 2.02 0.29-14.31 1.76 1.21-2.56
Abuse in current pregnancy RR
CI
*
3.44 1.58-Z49 3.16 1.14-8.72
1.84 1.29-2.63 1,62 0.77-3,41 1.72 0.66-4.49 1,94 1.31-2.90 1.58 0.63-3.98 1.65 0.49-5.54 2.04 1.38-3.02 2.93 1.31-6.58 1.61 0.53-4.85
RR = relative risk; CI = confidence interval.
*This cannot be calculated because there were no cases of abuse in pregnancy in the private insurance group.
involvement with the father of the infant. There was no significant difference in the m e a n estimated gestational age between abused and n o n a b u s e d w o m e n . H o w e v e r , 38% (six of 16) of w o m e n w h o were in an abusive relationship during the p r e g n a n c y registered later than 20 weeks' gestation, whereas 23% (72 of 318) of w o m e n w h o were not currently being abused registered after 20 weeks (P = .17).
Discussion The current ability to address the problems of domestic violence initially d e p e n d s on careful screening and identification. W o m e n w h o are being abused are often reluctant to admit to violence, in part because of shame, fear, and a belief that people will not u n d e r s t a n d or be able to help. One study 3 of prenatal patients f o u n d that only 8% of w o m e n filled out a form stating that they had been abused, but in that same g r o u p of w o m e n , 29% admitted to abuse w h e n questioned b y their prenatal care provider. Smith s f o u n d that detection rates i m p r o v e d w h e n more than one question pertaining to violence was asked during a single interview. In addition, increased detection has been noted with repeated questioning on multiple visits. 3 A l t h o u g h we assume our detection rate w o u l d increase with repeated interviews on multiple visits, this a p p r o a c h was not practical in this s t u d y because the social workers only performed repeated or follow-up interviews on patients with a positive screen for violence or with other social problems. Direct questioning seems to be an important tool. A s t u d y looking at trauma patients presenting to an
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emergency r o o m f o u n d that before a screen w a s instituted for domestic violence, only 5.6% of injuries were attributed to battering, whereas after the screen was instituted, 30% were attributed to violence. Eight years later in the same institution, the screen w a s no longer used, and domestic violence was cited by only 7.7% of t r a u m a patients. 9 In our study, a higher rate of domestic violence was detected in all categories using the Abuse Assessment Screen. Possibilities for this finding include the specific focus on abuse as well as the use of several targeted questions d u r i n g the interview. Previous studies 1"s'6'9 have noted associations between battering and other social risk factors, such as substance abuse, emotional problems, and lack of social support. In our study, h a v i n g public insurance or no insurance was associated with abuse in the current pregnancy. Also in our study, lack of involvement with the father of the infant was associated with a history of domestic violence as well as more recent abuse. This finding m a y be a response to the battering episode, although no definitive conclusions can be m a d e because the temporal relationship cannot be determined. Smoking, alcohol use, and a history of d r u g use were more c o m m o n in abused w o m e n , but the associations were not significant because of the limited sample size. Strengths of the s t u d y include a prospective evaluation of the Abuse Assessment Screen and a historical control g r o u p comparable to the s t u d y population. It m a y be considered a limitation that information from the routine social service interview was determined b y a retrospective chart review. H o w e v e r , the social w o r k d e p a r t m e n t confirmed that all ascertained cases of domestic violence w o u l d be clearly stated in the medical record with plans for referral. Adolescents and patients followed in our high-risk obstetric clinic were not included in the study, and this m a y limit generalizability to these g r o u p s because they m a y be at high risk for battering in pregnancy. A final limitation is that interviews in both g r o u p s took place only once early in pregnancy, which m a y underestimate battering in pregnancy. McFarlane et al 3 f o u n d a 17% incidence of battering d u r i n g p r e g n a n c y with higher yields on questioning during each trimester. Theories for this include a greater willingness to disclose abuse once rapport with a provider has been established and the longer time frame for abusive incidents to occur. In our study, all positive screens were referred to social workers w h o offered resources, including counseling, shelter, and legal aid. In addition, social workers followed these patients d u r i n g p r e g n a n c y and at delivery to ensure that the patients continued to have access to services. The goal of this social w o r k intervention is to discharge the patient and her n e w b o r n to a safe and secure environment.
Obstetrics & Gynecology
O u r s t u d y s u p p o r t s t h e u s e of five s i m p l e s t r u c t u r e d q u e s t i o n s to i n c r e a s e d e t e c t i o n rates of d o m e s t i c violence. A l l h e a l t h care p r o v i d e r s s h o u l d b e t r a i n e d to p e r f o r m u n i v e r s a l s c r e e n i n g u s i n g a t a r g e t e d s c r e e n for d o m e s t i c v i o l e n c e i n all p r e n a t a l p a t i e n t s . C l i n i c i a n s d e t e c t i n g d o m e s t i c v i o l e n c e s h o u l d b e a w a r e of t h e r e s o u r c e s i n t h e i r area a n d b e p r e p a r e d to p r o v i d e t e l e p h o n e n u m b e r s a n d referrals to p a t i e n t s . By detecti n g m o r e cases of b a t t e r i n g d u r i n g p r e g n a n c y , c l i n i c i a n s h a v e m o r e o p p o r t u n i t y to i n t e r v e n e a n d p r o t e c t t w o lives f r o m a d a n g e r o u s a n d p o t e n t i a l l y fatal e n v i r o n ment.
References 1. Hillard PJ. Physical abuse in pregnancy. Obstet Gynecol 1985;66: 185--90. 2. HeRon AS, McFaflane J, Anderson E. Battered and pregnant: A prevalence study. Am J Public Health 1987;77:1337-9. 3. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy: Severity and frequency of injuries and associated entry into prenatal care. JAMA 1992;267:3176-8. 4. Bullock L, McFaflane J. The birthweight/battering connection. Am J Nurs 1989;89:1153-5. 5. Amaro H, Fried L, Cabral H, Zuckerman B. Violence during pregnancy and substance use. Am J Public Health 1990;80:575-9.
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6. Campbell J, Poland M, Waller J, Ager J. Correlates of battering during pregnancy. Res Nurs Health 1992;15:219-26. 7. Parker B, McFarlane J, Soeken K. Abuse during pregnancy: Effects on maternal complications and birth weight in adult and teenage women. Obstet Gynecol 1994;84:323-8. 8. Smith MD. The incidence and prevalence of woman abuse in Toronto. Violence Vict 1987;2:173-87. 9. McLeer S, Anwar R, Herman S, Maquiling K. Education is not enough: A systems failure in protecting battered women. Ann Emerg Med 1989;18:651-3.
Address reprint requests to:
Jeffrey F. Peipert, MD Department of Obstetrics and Gynecology Women & Infant's Hospital 101 Dudley Street Providence, RI 02905
ReceivedJuly 28, 1994. Received in revisedform November21, 1994. Accepted November29, 1994 Copyright © 1995 by The American College of Obstetricians and Gynecologists.
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