Intimate partner violence (IPV) is, sadly, all too common, and it’s recognized as a clinical and public health issue. As nurses, we know it affects families of all racial, economic and religious backgrounds, affecting the family, the workplace and society at large.
Late last year, the Bureau of Justice Statistics of the U.S. Department of Justice released a report entitled “Intimate Partner Violence in the United States,” which found that statistics on IPV haven’t changed much in the past few years: “Domestic homicides against women rose from 1,155 murders in 2004 to 1,181 in 2005. That means that, on average, in 2005 more than three women a day were murdered by their husbands or boyfriends in the United States” (Family Violence Prevention Fund, 2007).
A study conducted by the Centers for Disease Control and Prevention (CDC) concluded that there are approximately two million injuries to women from IPV each year and that nearly one in four women report experiencing violence by a current or former spouse or boyfriend some time in her life. Additionally, it found that women who experience violence are at significantly greater risk for heart disease, stroke, asthma, arthritis and heavy drinking (Family Violence Prevention Fund, 2008).
According to the Family Violence Prevention Web site (http://www.endabuse.org), additional facts on IPV include the following:
- • Around the world, at least one in every three women has been beaten, coerced into sex or otherwise abused during her lifetime.
- • Nearly one-third of American women (31 percent) report being physically or sexually abused by a husband or boyfriend at some point in their lives, according to a 1998 Commonwealth Fund survey.
- • Nearly 25 percent of American women report being raped and/or physically assaulted by a current or former spouse, cohabiting partner or date at some time in their lifetime, according to the National Violence Against Women Survey, conducted from November 1995 to May 1996.
In the year 2001, more than half a million American women (588,490 women) were victims of nonfatal violence committed by an intimate partner.
Around the world, at least one in every three women has been beaten, coerced into sex or otherwise abused during her lifetime.
IPV and Pregnancy
Carrying an unborn child does not provide immunity against violence. As many as 324,000 women each year experience IPV during their pregnancy (Gazmararian et al., 2000). Since the 1970s, researchers have demonstrated that physical abuse during pregnancy is an important health risk to both the mother and the infant. It has been suggested that physical or sexual violence may be associated with an increased risk of miscarriage through increased stress, inadequate prenatal care, increased behavioral risks such as cigarette smoking and alcohol use, exacerbation of chronic illness and directed blows to the abdomen. One study found that adolescents who had experienced physical abuse were more likely to have a miscarriage (Jacoby, Gorenflow, Black, Wunderlich, & Eyler, 1999), rapid repeat pregnancy and experiences of interpersonal violence (Jacoby et al.).
Complications of IPV
Physical abuse before, during and after pregnancy is associated with many complications including sexually transmitted infections, such as bacterial vaginosis, Chlamydia trachomatis and HIV (King, Britt, McFarlane, & Hawkins, 2000), and group B streptococcus (Winn, Records, & Rice, 2003). IPV has also been associated with premature labor and low-birth-weight infants, although the literature is mixed on its influence. This is probably due to the various methods used to evaluate it. However, Rodrigues, Rocha, and Barros (2008) conducted a hospital-based survey on physical abuse during pregnancy and found that 24 percent of mothers of preterm newborn infants had experienced physical abuse during pregnancy compared with 8 percent of mothers of term newborn infants. Violence was associated with preterm birth even after controlling for many variables (Rodrigues et al.). The mechanism by which abuse might affect birth weight is not clear. Abuse may directly influence pregnancy by a blow or trauma to the uterus causing premature contractions or injury to the placenta. It may be due to the many medical conditions associated with abuse. Or abuse may indirectly affect the pregnancy by the stress from the abusive environment and the use of smoking and drugs used to alleviate it.
The Impact of Nurses
As nurses, we’re in an ideal position to help identify women at risk. Think of the number of women we come in contact with on a yearly basis. We also have the ability to establish a trusting relationship with our patients. If we are to be advocates of women and agents in ending the cycle of violence, identifying women experiencing IPV must be a priority for us. The research on IPV and specifically identifying women who are abused has been in the literature for the past two decades. In 1994, the Joint Commission on Health Care incorporated standards to identify abuse. Yet, years later, these standards of care are often not reflected in nursing care women receive from us.
We need to be cautious about asking the questions. Although it seems intuitive to screen in a sensitive and private manner, this may need to be reinforced to those who screen. Nursing for Women’s Health executive editor, Carolyn Davis Cockey, wrote eloquently in a commentary for this journal about her own experience of being assessed for abuse while pregnant (Cockey, 2003). She wrote: “It consisted of a checklist of screening items that could put my health at risk . . . such as cardiovascular disease, diabetes, hypertension. I was absolutely floored when she (the nurse) asked without looking up, ‘violence or abuse?’” This exchange occurred directly in front of her husband and son.
[ As nurses, we’re in an ideal position to help identify women at risk.. ]
One of my patients once explained it to me like this: “It’s all about how someone presents it. If it just seems like it’s a checklist on a piece of paper, it seems impersonal. And it feels like it doesn’t matter what your answer to the question is, because nobody will pay attention.” I have even overheard nurses laughing while asking, “You’re not abused, are you?”
One woman, who was a survivor of IPV, spoke to me about her first prenatal examination. The nurse asked her about abuse in a very matter-of-fact manner, as part of the total assessment. However, this woman was very concerned that her partner would walk into the room in the middle of the conversation and that the nurse would include him in the discussion. Therefore, it’s important that when we assess for abuse, we tell the woman exactly what will be done with the information and that if her partner walks into the room during the examination, we’ll change the subject.
Another issue with assessment is the incorporation of questions about abuse into screening forms. This may not be as innocuous as it may seem. Incorporating a screening into a form could be construed by an abuser as singling out his partner. One woman reported to me that when she was given a general health assessment form that had a question about abuse on it, her partner was looking over her shoulder as she filled out the form. She checked “no” to the question, but her partner believed she was asked the question because she was giving cues to the staff that she was abused—and that resulted in later violence.
We need to continue to educate ourselves about the necessity of screening, the complex issues associated with IPV and our own community resources to help deal with the problem. You never know when a patient is going to choose you as the person she confides in about her abuse. Remember, she may not confide in the first nurse who asks her the questions, or even to the second person, but at some point when she feels it’s safe, you may be the one she confides in. Nurses who care for women and who are advocates of prevention of abuse are in a perfect position to screen patients and to educate others on the importance of screening. Please do so in a caring, confidential nonjudgmental manner.
Barbara A. Moran, PhD, MPH, MS, CNM, FACCE, is an assistant professor in the School of Nursing at Catholic University of America in Washington, DC and is the 2008 AWHONN President.