Linda E. Saltzman

Screening for intimate partner violence by health care providers. Barriers and interventions.

INTRODUCTION Routine screening for intimate partner violence (IPV) is endorsed by numerous health professional organizations. Screening rates in health care settings, however, remain low. In this article, we present a review of studies focusing on provider-specific barriers to screening for IPV and interventions designed to increase IPV screening in clinical settings. METHODS A review of published studies containing original research with a primary focus on screening for IPV by health professionals was completed. RESULTS Twelve studies identifying barriers to IPV screening as perceived by health care providers yielded similar lists; top provider-related barriers included lack of provider education regarding IPV, lack of time, and lack of effective interventions. Patient-related factors (e.g., patient nondisclosure, fear of offending the patient) were also frequently mentioned. Twelve additional studies evaluating interventions designed to increase IPV screening by providers revealed that interventions limited to education of providers had no significant effect on screening or identification rates. However, most interventions that incorporated strategies in addition to education (e.g., providing specific screening questions) were associated with significant increases in identification rates. CONCLUSION Barriers to screening for IPV are documented to be similar among health care providers across diverse specialties and settings. Interventions designed to overcome these barriers and increase IPV-screening rates in health care settings are likely to be more effective if they include strategies in addition to provider education.

The relationship between pregnancy intendedness and physical violence in mothers of newborns

Objective To determine if pregnancy intendedness is associated with physical violence, and to identify factors that modify this association. Methods Three to 6 months after delivery, we mailed a questionnaire to a population-based sample of 12,612 mothers of infants born during 1990 and 1991 in four states. We used multiple logistic regression to compute odds ratios. Results The state-specific prevalences (± standard error) of physical violence ranged from 3.8 ± 0.5 to 6.9 ± 0.8%; the prevalences of unwanted or mistimed pregnancies ranged from 36.9–46.3%. In each state, higher rates of physical violence were reported by women who had fewer than 12 years of education, lived in crowded conditions, participated in the Special Supplemental Food Program for Women, Infants, and Children, received no or delayed prenatal care, or were of races other than white, under 20 years old, or not married. Regardless of other attributes, women with unwanted or mistimed pregnancies reported higher rates of physical violence than women with intended pregnancies and accounted for 70% of women who reported physical violence. Overall, women with unwanted pregnancies had 4.1 (95% confidence interval 2.7–6.2) times the odds of experiencing physical violence than did women with intended pregnancies. This association was weaker for women with few social advantages than for those with more advantages. Conclusion Physical violence toward women during the periconceptional and antenatal periods occurs in all sociodemographic groups. Women with unwanted or mistimed pregnancies are at an increased risk for violence by their partners compared with women with intended pregnancies.

Perceived Risk and Social Control: Do Sanctions Really Deter?

Perceptual deterrence researchers have used simple crosssectional correlations between prior behavior and current perceptions to study the effect of legal threats on social control. Such designs are inadequate because they: (1) confuse the causal ordering of perceptions and behavior, and (2) fail to take into account other inhibitory factors in an explicit causal model. In an analysis of panel data, the methodological simplicity of earlier studies is shown to have led researchers to reach erroneous conclusions. Our data suggest that past studies report an experiential effect, not a deterrent effect, and that the effect of perceived sanctions on criminal involvement is minimal once social definitional factors (moral commitment, informal sanctions) are controlled.

Violence and Reproductive Health: Current Knowledge and Future Research Directions

Objectives: Despite the scope of violence against women and its importance for reproductive health, very few scientific data about the relationship between violence and reproductive health issues are available. Methods: The current knowledge base for several issues specific to violence and reproductive health, including association of violence with pregnancy, pregnancy intention, contraception use, pregnancy terminations, and pregnancy outcomes, are reviewed and suggestions are provided for future research. Results: Despite the limitations of current research and some inconclusive results, the existing research base clearly documents several important points: (1) violence occurs commonly during pregnancy (an estimated 4%–8% of pregnancies); (2) violence is associated with unintended pregnancies and may be related to inconsistent contraceptive use; and (3) the research is inconclusive about the relationship between violence and pregnancy outcomes. Conclusions: Improved knowledge of the risk factors for violence is critical for effective intervention design and implementation. Four areas that need improvement for development of new research studies examining violence and reproductive-related issues include (1) broadening of study populations, (2) refining data collection methodologies, (3) obtaining additional information about violence and other factors, and (4) developing and evaluating screening and intervention programs. The research and health care communities should act collaboratively to improve our understanding of why violence against women occurs, how it specifically affects reproductive health status, and what prevention strategies may be effective.

Pregnancy intendedness and physical abuse around the time of pregnancy: findings from the Pregnancy Risk Assessment Monitoring System 1996-1997.

Objective: This study examines whether unintended pregnancy is associated with physical abuse of women occurring around the time of pregnancy, independent of other factors. Methods: In 1996–1997, state-specific population-based data were obtained from the Pregnancy Risk Assessment Monitoring System (PRAMS) from 39,348 women in 14 states who had delivered a live-born infant within the previous 2–6 months. The study questionnaire asked about maternal behaviors and characteristics around the time of pregnancy. Results: Women who had mistimed or unwanted pregnancies reported significantly higher levels of abuse at any time during the 12 months before conception or during pregnancy (12.6% and 15.3%, respectively) compared with those with intended pregnancies (5.3%). Higher rates of abuse were reported by women who were younger, Black, unmarried, less educated, on Medicaid, living in crowded conditions, entering prenatal care late, or smoking during the third trimester. Overall, women with unintended pregnancies had 2.5 times the risk of experiencing physical abuse compared with those whose pregnancies were intended. This association was modified by maternal characteristics; the association was strongest among women who were older, more educated, White, married, not on Medicaid, not living in crowded conditions, receiving first trimester prenatal care, or nonsmoking during the third trimester. Conclusions: Women with unintended pregnancies are at increased risk of physical abuse around the time of pregnancy compared with women whose pregnancies are intended. Prenatal care can provide an important point of contact where women can be screened for violence and referred to services that can assist them.

Fatal violence among spouses in the United States, 1976-85.

In this paper we examine patterns and trends in homicides between marriage partners in the United States for 1976 through 1985 using data from the Federal Bureau of Investigations Supplemental Homicide Reports (FBI-SHR). We identified 16,595 spouse homicides accounting for 8.8 per cent of all homicides reported to the FBI-SHR during this 10-year period. The rate of spouse homicide for this 10-year period was 1.6 per 100,000 married persons. The risk of being killed by ones spouse was 1.3 times greater for wives than for husbands. Black husbands were at greater risk of spouse homicide victimization than Black wives or White spouses of either sex. The risk of victimization was greater for spouses in interracial than in intraracial marriages and increased as age differences between spouses increased. From 1976 through 1985, the risk of spouse homicide declined by more than 45.0 per cent for both Black husbands and wives but remained relatively stable for White husbands and wives. Demographic patterns in the risk of spouse homicide were similar to those reported for nonfatal spouse abuse suggesting that the causes of spouse homicide and nonfatal spouse abuse may be similar.

Prevalence and characteristics of sexual violence victimization among U.S. adults, 2001-2003.

This article provides the most recent U.S. prevalence estimates of forced sex and unwanted sexual activity. Results of a national telephone survey conducted in 2001–2003 indicate that 1 in 59 U.S. adults (2.7 million women and 978,000 men) experienced unwanted sexual activity in the 12 months preceding the survey and that 1 in 15 U.S. adults (11.7 million women and 2.1 million men) have been forced to have sex during their lifetime. There were 60.4% of females and 69.2% of males who were 17 years old or younger at the time the first forced sex occurred. This study provides an update to the National Violence Against Women Survey with more recent national data. Findings suggest that victimization rates have remained consistent since the 1990s. These findings suggest that a continued effort toward primary prevention of sexual violence, particularly rape of children and adolescents, is needed.

Homicide: A Leading Cause of Injury Deaths Among Pregnant and Postpartum Women in the United States, 1991–1999

OBJECTIVES We identified risk factors for pregnancy-associated homicide (women who died as a result of homicide during or within 1 year of pregnancy) in the United States from 1991 to 1999. METHODS Pregnancy-associated homicides were analyzed with data from the Pregnancy Mortality Surveillance System at the Centers for Disease Control and Prevention. RESULTS Six hundred seventeen (8.4%) homicide deaths were reported to the Pregnancy Mortality Surveillance System. The pregnancy-associated homicide ratio was 1.7 per 100000 live births. Risk factors included age younger than 20 years, Black race, and late or no prenatal care. Firearms were the leading mechanism for homicide (56.6%). CONCLUSIONS Homicide is a leading cause of pregnancy-associated injury deaths.

Physical Abuse Around the Time of Pregnancy: An Examination of Prevalence and Risk Factors in 16 States

Objectives: From self-reports we describe and compare the levels and patterns of physical abuse before and during pregnancy while also describing the demographic and pregnancy-related characteristics of physically abused women, the stressful experiences of abused women prior to delivery, and the relationship of the abused woman to the perpetrator(s). Methods: We used population-based estimates from the Pregnancy Risk Assessment Monitoring System (1996–98) to calculate a multiyear 16-state prevalence with 95% confidence intervals (CIs) and unadjusted risk ratios for demographic, pregnancy-related, and stressful experiences variables. Results: We found the prevalence of abuse across the 16 states to be 7.2% (95% CI, 6.9-7.6) during the 12 months before pregnancy, 5.3% (95% CI, 5.0–5.6) during pregnancy, and 8.7% (95% CI, 8.3–9.1) around the time of pregnancy (abuse before or during pregnancy). The prevalence of physical abuse during pregnancy across the 16 states was consistently lower than that before pregnancy. For time periods both before and during pregnancy, higher prevalence was found for women who were young, not White, unmarried, had less than 12 years of education, received Medicaid benefits, or had unintended pregnancies, and for women with stressful experiences during pregnancy, particularly being involved in a fight or increased arguing with a husband or partner. For each of these risk groups, the prevalence was lower during pregnancy than before. Abuse was ongoing before pregnancy for three quarters of the women experiencing abuse by a husband or partner during pregnancy. Conclusions: Women are not necessarily at greater risk of physical abuse when they are pregnant than before pregnancy. Both the preconception period and the period during pregnancy are periods of risk, which suggests that prevention activities are appropriate during routine health care visits before pregnancy as well as during family planning and prenatal care.

National Trends in Intimate Partner Homicide United States, 1976-1995

The authors investigated U.S. trends in intimate partner homicide stratified by relationship type and race during the period 1976 to 1995. Data sources were the Supplemental Homicide Reports and the United States Current Population Survey. Rates of homicide victimization decreased during the past 20 years among all intimate partners except for White, unmarried females. The authors explore possible explanations for these trends. Results replicate previous findings regarding downward national trends in partner homicides, but with three methodological differneces. The authors examined spouses and exspouses separately, used de- nominator data that were specific to the population at risk, and included same-sex partners.