Protocols target pregnant domestic abuse victims

Abuse often begins in pregnancy

(Editor's note: In this issue of Women's Health Center Management, we begin the first of a two-part series on domestic violence and pregnancy. The following article discusses the link between violence and pregnancy and how to increase awareness, screening, and prevention at your facility. Next month's issue will profile an award-winning program that established a protocol for a hospital system to treat victims of domestic violence. We'll also give you some shocking statistics from a study of domestic violence victims.)

Despite the national attention domestic violence has received in recent years, little research has focused on victims who are pregnant - although pregnancy often ignites the abuse. Emerging statistics on violence against pregnant women are haunting.

Kathleen Furniss, MSN, nurse practitioner in women's health at the University of Medicine and Dentistry in Newark, NJ, says that of the 2 million to 4 million women who are assaulted by their partners each year, one in six are pregnant.

"Women in abusive relationships are at risk for serious physical problems, such as injury, miscarriage, premature labor, low birth weight delivery, substance abuse, and even death," she says. "The attacks are repetitive, intentional, and exacerbate over time." What's more, Furniss says, the attacks frequently begin at pregnancy.

"In an abusive relationship, the abuser controls his partner to fulfill his self-esteem, so you can see why pregnancy exacerbates abuse," explains Kathleen Slammon, MSW, CSW, director of Safe Passage, a domestic abuse program at Sisters Hospital, Buffalo, NY. "During this time, the pregnant woman has a number of health care providers and family involved with her life, and she is focused on taking care of herself and the pregnancy. The attention is taken away from her partner, which causes the abuser to feel isolated and jealous and afraid of losing control over her.

"It's often when victims are pregnant that they seek help because they see their pregnancy in danger," Slammon says. "However, it's difficult for them because many of the partners are older, and the victim is financially dependent on them. Leaving means having no other resources."

Abuse in pregnancy is associated with increased used of tobacco, alcohol, and illicit drugs, Furniss says. "What's more, pregnant adolescents are at very high risk, as 22% of pregnant teens are in abusive relationships," she says.

As more research on this topic comes to light, health care professionals are increasing their awareness about the extent of the problem and the role they play in preventing it. Screening is key.

"When you look at the magnitude of the entire problem, the prevalence of domestic violence is higher than most diseases that are screened for during pregnancy," says Eileen Meisner, BSN, coordinator of Women's and Family Services at Lutheran Medical Center in Wheat Ridge, CO. "Just as it would be negligent not to screen for things like blood-type compatibility and gestational diabetes, so it's negligent not to screen for domestic abuse."

However, routine screening isn't offered by many providers. "From a medical point of view, there has not been a lot of research in this area, so it's not something health care providers are trained to think about," she says. "And although health care providers talk about very intimate things like sexuality with their patients, they're afraid of offending patients when it comes to domestic abuse."

Time constraints add to the problem because it's not something that can be ascertained quickly, she says. Also, domestic violence can be hard to identify since it's frequently unnoticeable, with victims having vague complaints and various injuries in different stages of healing. "Battered women may be injured and bleeding in the ER but healthy and smiling in non-emergent visits," Furniss says. "Therefore, it's essential for women's health settings to have a high index of suspicion for every female patient."

Meisner says, "The problem is that there are no defined risk factors - the demographics are all over the place. Sometimes we can recognize domestic abuse because of suicide attempts, depression, or because they have repetitive psychosomatic complaints. We try to pick up on clues and ask direct questions. Another clue is the partner's behavior. Abusive partners will be overly concerned about their pregnant wife or girlfriend. They're very controlling, so they won't leave the patient's room and want to answer all questions for her. Once we can get the male partner to leave, we ask the patient if she feels safe."

Meisner says Lutheran Medical Center has made identification and referral of abuse victims a priority. Last year, the entire hospital was required to attend training by Assault Survivors Assistance Program, the hospital's domestic violence program.

"It's important to explain that health care professionals should not see themselves as experts in partner violence; rather that their responsibility is to incorporate screening into their areas by identifying and reporting," says Meisner. "Because of the training, people throughout the hospital now are more comfortable in addressing domestic abuse because they understand their obligation."