Ruth Petersen

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.

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.

Hospitalizations during pregnancy among managed care enrollees.

OBJECTIVE To describe the prevalence of hospitalizations during pregnancy, the reason for hospitalization, the length of stay, and the associated costs. METHODS We analyzed data from a national managed care organization and determined the occurrence of hospitalizations for 46,179 women who had a live birth or a pregnancy loss in 1997. RESULTS Overall, 8.7% of women were hospitalized during their pregnancy. Of these, 5.7% were hospitalized and discharged while pregnant, 0.8% experienced extended stays before a live birth or pregnancy loss, and 2.1% experienced pregnancy loss. Hospitalizations were more common among younger women, women with multiple gestations, and women in the northeastern United States. Women who had a live birth were primarily hospitalized for preterm labor (24%), hyperemesis (9%), hypertension (9%), kidney disorders (6%), and prolonged premature rupture of membranes (6%). Charges totaled over

Partner violence: implications for health and community settings.

36 million. CONCLUSION Antenatal hospitalizations are common.

Defining and Measuring Unintended Pregnancy: Issues and Concerns

OBJECTIVE To assist in the design and implementation of strategies to address partner violence, the objective of this study was to evaluate differences in mental health, health behaviors, and use of health care and specific community services between women who do or do not report experiences of partner violence as an adult. METHODS During interviews with 392 women enrolled in a Medicaid managed care organization, measures of mental health status, health behaviors, use of health care and community services, and experiences of partner violence were collected. Using bivariate statistical analyses, characteristics between women reporting or not reporting partner violence were compared. Chi-square tests were used to assess significant differences between the groups. The relationships between outcomes of interest and violence were estimated with logistic regression models adjusting for significant demographic and health characteristics. RESULTS Overall, 28% of women reported experiences of partner violence. Women reporting partner violence had twice the adjusted odds of depression and three times the adjusted odds of negative self-esteem compared with women not reporting experiences of partner violence. Women reporting partner violence, compared with those who did not, indicated higher use of specific types of health and community services such as mental health services [odds ratio (OR) 2.9; confidence interval (CI) 1.5-5.6] and individual counseling (OR 3.6; CI 2.2-6.1). CONCLUSIONS A communitywide effort that establishes linkages between health care settings and community services may be important in addressing the needs of women who are experiencing partner violence.

Pregnancy and STD prevention counseling using an adaptation of motivational interviewing: a randomized controlled trial.

This article of the past and current measures of unintendedness of pregnancy has been offered in the hope that investigation into this area can be expanded. Current information available from available national surveys is not comparable due to different survey questions, inclusion criteria, and timing of interviews. What are often reported as rates of unintendedness may be rates of unwantedness--a completely different concept. Many studies fail to delineate the distinction between those unintended pregnancies that are indeed unintended versus those that were mistimed. Potentially, these existing data sets could be reanalyzed by using specific inclusion criteria for unintendedness, maternal age, and marital status. This information might be helpful in improving the comparability between the surveys and in assessing trends in unintendedness. In the future, to accurately measure unintendedness of pregnancy, we must use a consistent definition that takes into account the complexities of the issue. Valid and reliable scales that reflect the value of unintendedness from the mothers perspective need to be developed to reflect the potential change in intendedness over time. The adequate measurement of unintendedness of pregnancy is the first step in addressing the Healthy People 2000 goal and measuring progress in addressing the nations reportedly high rate in the long-term goal of addressing the risk factors of unintended pregnancy.

Preventive counseling during prenatal care. Pregnancy risk assessment monitoring system (PRAMS)

CONTEXT Given levels of unintended pregnancy and STDs, an effective counseling intervention is needed to improve womens consistent use of effective prevention methods. METHODS A sample of 764 women aged 16-44 who were at risk of unintended pregnancy were enrolled in a randomized controlled trial in North Carolina in 2003-2004. Intervention participants received pregnancy and STD prevention counseling, adapted from motivational interviewing, both at enrollment and two months later; controls received only a session of general health counseling. Levels of contraceptive use (categorized as high, low or none on the basis of the effectiveness of the method and the consistency of use) and barriers to use were measured at two, eight and 12 months; chi-square tests were used to compare selected outcomes between the groups. Rates of unintended pregnancy and chlamydia infection were assessed over the study period. RESULTS At baseline, 59% of all participants reported a high level of contraceptive use, 19% a low level and 22% nonuse. At two months, the proportions of intervention and control participants who had improved their level of use or maintained a high level (72% and 66%, respectively) were significantly larger than the proportions who had reported a high level of use at baseline (59% and 58%, respectively). No significant differences were found between the groups at 12 months, or between baseline and 12 months for either group. During the study, 10-11% of intervention and control participants became pregnant, 1-2% received a chlamydia diagnosis and 7-9% had another STD diagnosed. CONCLUSIONS Repeated counseling sessions may be needed to improve contraceptive decision-making and to reduce the risk of unintended pregnancy and STDs.

Violence against women and reproductive health: toward defining a role for reproductive health care services

BACKGROUND Prenatal care provides an opportunity for counseling about behaviors and experiences that increase the likelihood of adverse maternal and fetal outcomes. OBJECTIVE To document (1) prevalence of preventive health counseling during prenatal care, (2) prevalence of women in higher need of counseling about specific health concerns, and (3) whether women in higher need for counseling were more likely than women in lower need to have received counseling. METHODS Analysis of the Pregnancy Risk Assessment Monitoring System (PRAMS), a state-specific, population-based, random sample of postpartum women, was performed by using data from 14 states for births during 1997 or 1998, for a total of 24,620 participants. Outcome measures included report of preventive health counseling during prenatal visits by specific topic as well as behaviors and experiences about cigarette use, alcohol use, breast-feeding, partner violence, and preterm labor. RESULTS The percentage of women that report preventive counseling during prenatal care is relatively high (> or =75%) for 9 of 13 topics. However, the percentage of women that report counseling is relatively low (<75%) for partner violence, seat belt use, illegal drug use, and human immunodeficiency virus (HIV) risk. Except for counseling about cigarette and alcohol use, women in higher need, compared with women in lower need, for three other health topics were not significantly more likely to receive counseling. CONCLUSIONS Preventive health counseling for partner violence, seat-belt use, illegal drug use, and risk of HIV could be increased across prenatal settings. Counseling should involve assessment of risks, with focused counseling related to those risks.

Medicaid reimbursement for prenatal smoking intervention influences quitting and cessation

Since a large proportion of U.S. women receive reproductive health care services each year, reproductive health care settings offer an important opportunity to reach women who may be at risk of or experiencing intimate partner violence (IPV). Although screening women for IPV in clinical health care settings has been endorsed by national professional associations and organizations, scientific evidence suggests that opportunities for screening in reproductive health care settings are often missed. This commentary outlines what is known about screening and intervention for IPV in clinical health care settings, and points out areas that need greater attention. The ultimate goal of these recommendations is to increase the involvement of reproductive health care services in sensitive, appropriate, and effective care for women who may be at risk of or affected by IPV.

Stressful life events and physical abuse among pregnant women in North Carolina.

Background: 40% of births in the USA are covered by Medicaid and smoking is prevalent among recipients. The objective of this study was to evaluate the association between levels of Medicaid coverage for prenatal smoking cessation interventions on quitting during pregnancy and maintaining cessation after delivery. Methods: Population based survey study of 7513 post-partum women from 15 states who: participated in Pregnancy Risk Assessment Monitoring System (PRAMS) during 1998–2000; smoked at the beginning of their pregnancy; and had Medicaid coverage. Participating states were categorised into three levels of Medicaid coverage for smoking cessation interventions during prenatal care: extensive (pharmacotherapies and counselling); some (pharmacotherapies or counselling); or none. Quit rates among women who smoked before pregnancy and rates of maintaining cessation were examined. Results: Higher levels of coverage during prenatal care for smoking cessation interventions were associated with higher quit rates; 51%, 43%, and 39% of women quit in states with extensive, some, and no coverage, respectively. Compared to women in states with no coverage, women in states with extensive coverage had 1.6 times the odds of quitting smoking (odds ratio (OR) 1.58, 95% confidence interval (CI) 1.00 to 2.49). Maintenance of cessation after delivery was associated with extensive levels of Medicaid coverage; 48% of women maintained cessation in states with extensive coverage compared to 37% of women in states with no coverage. Compared to women in states with no coverage, women with extensive coverage had 1.6 times the odds of maintaining cessation (OR 1.63, 95% CI 1.04 to 2.56). Conclusions: Prenatal Medicaid coverage for both pharmacotherapies and counselling is associated with higher rates of quitting and continued cessation. This suggests policymakers can promote cessation by broadening smoking cessation services in Medicaid prenatal coverage.