Isabelle Jeanjot, Patricia Barlow, and Serge Rosenberg's recently published article in the Journal of Women's Health highlights the alarming prevalence of intimate partner violence in pregnancy.  According to their literature review, between 3 and 17 percent of pregnant women suffer from domestic violence.  Although the link between intimate partner violence and pregnancy is well established, direct causes are less clear.  Yet, regardless of what provokes it, physical abuse during pregnancy can have tragic ramifications.  Placental abruption and miscarriage are just two of the possible physiological consequences.

While Jeanjot et al's article focuses specifically on domestic violence in pregnancy; their article also underscores the critical issue of domestic violence generally.  Domestic violence is the leading cause of injury to women aged 15 to 44 years of age, outnumbering automotive accidents, muggings, and rapes combined.  As healthcare providers it is our responsibility to stay attuned to the potential signs and symptoms of intimate partner violence.  Cuts, bruising, frequent ER visits, and dubious explanations for injuries are obvious red flags.  However, it is also important to remember that violence extends beyond the merely physical.  More subtle, but just as destructive, are situations in which partners subject women to verbal or psychological manipulation.  We must listen carefully to the covert clues or patients' reveal.

Before initiating routine screening, become familiar with the protocol at your institution.  You do not want to find yourself scrambling for referrals or impotent to help should you discern that your patient is indeed the victim of domestic partner abuse.  Get to know the resources in your area; emergency hotlines, anonymous shelters, legal consults, and counseling services.  Have these numbers posted in discreet places, such as tear-off flyers in clinic bathrooms, and consider printing plain business-sized cards listing important numbers.  Additionally, all heath care workers should know their state reporting laws.  You can find these regulations at www.fvpf.org/statereport.

How does one introduce the issue of domestic violence into a patient encounter in a way that is sensitive, appropriate, and that encourages women to share painful, difficult, and shameful aspects of their intimate relationships?  The easiest approach to screening is to employ a verbal SAFE questionnaire.  These questions should always be asked without partners present.

 

Stess/ Safety

- What stresses do you have in your relationship with your partner?

- Do you feel safe in your relationship with your partner?

Afraid

- Have you ever been threatened or abused?

- Are there situations in which you feel afraid?

Friends/Family

- (if yes to above) Are your friends and family aware of this?

- (if no to above) Could you tell them if it did happen?

Emergency Plan

- Do you have a safe place to go in an emergency?

- If you are in danger now, may I help you find a shelter?

- Would you like to talk with a social worker or counselor?

There is no "correct" method for managing patients who are involved in abusive living situations.  Our patients are ultimately responsible for whether or not they remain in unhealthy relationships.  However, we can empower women to consider alternative choices, choices which prioritize their own health and safety, and, in the case of pregnant women, the health and safety of future children.  Minimally, we can help women draft safety plans.  Additionally, we can encourage our clients to talk to trusted friends and family members.  Sometimes all it takes for a woman to gain the courage to leave an abusive relationship is the presence of someone who listens to her story, does not judge her circumstances, supplies her with alternatives options, and supports her decision to change her life.   

References:

Jeanjot, I. et al. (2008). Domestic Violence and Pregnancy:  Survey of Patients and

Healthcare Providers. Journal of Women's Health, 17(4), 557-567.

Uphold, C. & Graham, M. (2003).  Clinical Guidelines in Family Practice. 

Gainesville, FL:  Barmarrae Books, Inc.

 

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