A Hidden Crisis During COVID-19: How Have Intimate Partner Violence Screening Guidelines for Pregnant Patients Changed Since the Start of the Global COVID-19 Pandemic?

Abstract

Introduction: Due to the risks of pregnancy outcomes in relation to IPV and the increased rates of IPV as a result of COVID-19 precautions, health care screening for IPV in the prenatal process is even more imperative for preventing negative healthcare outcomes for both the pregnant patient and children. Background: Intimate partner violence (IPV) is a significant public health issue that puts both baby and pregnant patients at risk for severe negative healthcare outcomes. Healthcare screening is a tool to find a condition or to learn more about a patient before symptoms become severe. Methods: Screening for IPV and the effects of COVID-19 on rates of IPV were reviewed individually. A semi-structured interview was developed to learn more about how obstetricians approach screening of pregnant patients. Twenty-three physicians were emailed for informational interviews. Results: Three (18.8%) physicians agreed to be interviewed. Three main themes were identified during the interviews. There was no formal IPV training, the confidentiality necessary to screen a patient for IPV has been compromised since many appointments with pregnant patients have moved from in-person to virtual, and third, the lack of childcare in clinics is a limiting factor for the possibility for pregnant patients to attend regular appointments because of the Covid-19 social distancing restrictions and guidelines. Conclusion: The biggest barriers found during this research were not training procedures themselves but the uncontrollable variables that have been further complicated by the pandemic. Future research needs to go into the screening practices and capabilities in the virtual arena now that telehealthcare will likely be available beyond the Covid-19 pandemic. Introduction The World Health Organization labeled COVID-19 a global pandemic on March 11th, 2020. Since then, there have been countless stay-at-home orders across the United States of America, which has, in turn, played a large part in a surge of Intimate partner violence (IPV) cases due to increased isolation. (Kofman, 2020). There is substantial research connecting the presence of IPV during pregnancy with adverse pregnancy outcomes like preterm birth (PTB) and low birth weight (LBW) (O’Reilly, 2010). Both instances of IPV and COVID-19 are disproportionately prevalent amongst BIPOC (Black, Indigenous, and People of Color) communities (Stockman, 2015 and Valenzuela, 2020). Due to the risks of pregnancy outcomes in relation to IPV and the increased rates A Hidden Crisis During COVID-19 of IPV as a result of COVID-19 precautions, health care screening for IPV in the prenatal process is even more imperative for preventing negative healthcare outcomes for both the pregnant patient and children. Protocols for screening procedures with the intent to center the safety of potential patients experiencing IPV set long before the start of the global pandemic are now complicated with barriers introduced by COVID-19 thus placing pregnant patients, and especially those identifying as BIPOC, in higher states of risk for negative health outcomes. The purpose of this study is to learn if physicians have had specialized training regarding IPV screening, what screening procedures physicians use during appointments with pregnant patients, how COVID-19 has altered screening practices, and to explore the implications for BIPOC patients. Background Intimate partner violence (IPV) is a significant public health issue that puts both baby and pregnant patients at risk for severe negative healthcare outcomes. The Center for Disease Control (2020) defines IPV as “physical violence, sexual violence, stalking, or psychological harm by a current or former partner or spouse.” Exposure to IPV has been shown to increase the risk of spontaneous abortion, fetal loss, PTB, LBW, and neonatal death (Alhusen, 2015). Approximately 42.4 million (35.6%) women in the United States have experienced IPV within their lifetime. Intimate partner violence has had a 20% increase globally during the COVID-19 pandemic (Miller, n.d.). The National Intimate Partner and Sexual Violence Survey indicates the prevalence of IPV amongst non-Hispanic Black and Native American/Alaskan Native women is significantly higher (43.7% and 46% respectively) compared to non-Hispanic white women (34.6%) (Stockman, 2015). A Hidden Crisis During COVID-19 Healthcare screening is a tool to find a condition or to learn more about a patient before symptoms become severe. Regular health care screening is a part of yearly check-ups, for example. Some familiar questions that a primary care provider has most likely asked patients could be: Do you have a family history for diabetes? Do you use tobacco? How often do you drink alcohol? How many sexual partners do you have? Etc. Most healthcare providers should ask similar questions specifically geared toward assessing the possibility of IPV in a pregnant patient. Literature Review In 1992 the American Medical Association (AMA) recommended that all women who access primary care (and some secondary care facilities) get screened for IPV (American Medical Association Diagnostic and Treatment Guidelines on Domestic Violence, 1992). However, despite recommendations, the approach to screening for IPV during pregnancy is not universal. The CDC in 2004 concluded that “the extent to which US clinicians incorporate screening for IPV into their practices is relatively unknown” (Bailey, 2010). More recently in 2015, despite the recommendations of the United States Preventive Services Task Force (USPSTF), studies have shown that only 1.5%-12% of pregnant patients get screened for IPV despite the fact that 96% receive prenatal care (Intimate Partner Violence Screening, 2015). Screening is a tool to identify IPV in a pregnant patient which allows providers a unique ability to detect IPV early due to elongated relationships with the patient throughout their pregnancy. If IPV is detected early during screening it may even help prevent adverse effects on maternal and pregnancy outcomes. In a systematic literature review, Bailey (2010) found at that time A Hidden Crisis During COVID-19 numerous organizations and healthcare providers had recommended a universal screening procedure, but there did not appear to be a universal practice in place. The 2017 Women s Health Survey conducted by the Kaiser Family Foundation (KFF) shows that in 2017 only 27% of women reported they were screened for IPV with a medical provider and women who were low-income, on Medicaid, and/or identified as Black or Latina were the most likely to be screened (Gomez et al., 2018). Researchers went on to specify that Latina women and women covered by Medicaid were significantly more likely to seek care from community health centers or clinics and argued that clinics are essential to the care of women of color. Community health centers that frequently serve marginalized populations would know the barriers their patients are predisposed to thus offering a possible reason why women on Medicaid and/or Black and Latina women were more likely to be screened. The U.S. Preventive Services Task Force (USPSTF) reviewed a number of screening tools and came up with a list of six they recommended for their sensitivity and specificity: HITS (Hurt, Insult, Threaten, Scream), OVAT (Ongoing Violence Assessment Tool), STaT (Slapped, Things, and Threaten), HARK (Humiliation, Afraid, Rape, Kick), CTQ-SF (Modified Childhood Trauma Questionnaire– Short Form), WAST (Women Abuse Screen Tool) (Agency for Healthcare Research and Quality [AHRQ], 2015). Four of the six screening tools are discussed in a PDF document from the CDC in a collection of almost one hundred other screening tools designed by variations of doctors, non-profit organizations, universities, clinics, and hospitals (Center for Disease Control [CDC], 2007). The STaT screening tool must be purchased from an outside organization but is referenced. Each one uses a scoring process to determine the level of risk. Providers without training or extensive knowledge may have a difficult time A Hidden Crisis During COVID-19 understanding the differences, deciding which one to use, and learning how to implement with the safety of a patient in mind. The CDC’s endorsement of so many screening tools rather than a set of universally recommended standards runs the risk of confusing providers and causing a lowered rate of screening or, more dangerously, improper screening that could put the patient in further danger. The Agency for Healthcare Research and Quality (AHRQ) recommends numerous screenings for IPV at “periodic intervals, including obstetric care at the first prenatal visit, at least once per trimester, and at the postpartum checkup” which is in accordance with other official organizations such as the United States Department of Health and Human Services (HHS) and the Institute of Human Medicine (IOM) (AHRQ, 2015). Authors Ramaswamy, Ranji, and Salganicoff (2019) also discuss IPV screening tools in their recent study published by the Kaiser Family Foundation (KFF) in which they agree with the AHRQ’s recommendations for screening intervals and further explore barriers to the screening process. They argue that the main barriers providers face with regards to IPV screening is the presence of a partner, lack of time to build a relationship that would encourage patients to disclose, patients’ concerns about mandatory reporting laws, and lack of adequate knowledge about the issue of IPV and screening procedures itself (possibly explained by the number of screening tools available to them rather than a clear set of universal guidelines). The COVID-19 pandemic forced national stay-at-home mandates across the United States which have forced victims of IPV to be isolated with their abusers. Intimate partner violence hotlines expected to see states increase the demand for their services. However, many organizations have seen major declines i