Domestic Violence Screening in Adolescent Pregnancy

Anisha Abraham, Maj, MD, MPH

Objectives

• To provide an overview of domestic violence as a public health issue

• To review key causes and risk factors of domestic violence during teen pregnancy

• To discuss the role of health care providers in domestic violence prevention

Domestic Violence and Women

• Domestic violence is the leading cause of injury to women between the ages of 15-44. (CDC, 1999)

• Every 21 days, a woman is killed by domestic violence. (U.S. Department of Justice, 1998)

• More than 5 million females experience some form of violence each year. Almost two of every three of these females are attacked by a relative or person known to them. (The Commonwealth Fund, 1998)

Domestic Violence and Women

• 34% of adults in the United States had witnessed a man beating his wife or girlfriend, and 14 % of women report that they have experienced violence from a husband or boyfriend. (U.S. Department of Justice's National Crime Victimization Survey, 1998)

• More than 1 million women seek medical assistance each year for injuries caused by battering. (U.S. Department of Justice's National Crime Victimization Survey, 1998)

Domestic Violence and Pregnancy

• The prevalence of violence during pregnancy (all ages) ranges from 4-8% (Gazamarian JA. Prevalence of violence against women.. JAMA 1996)

• Higher rates are identified when screening occurs more than once during the pregnancy (Macfarlane J. Assessing for abuse during pregnancy. JAMA. 1992.)

• The pattern of violence may escalate during pregnancy and may be more prevalent in the postpartum period (Helton AS. Battered and pregnant: a prevalence study. Am J Pub Health. 1987)

Violence and Teen Pregnancy

• Women < 18 yrs were twice as likely to have experienced violence during and after pregnancy then older women (Gessner BD. Experience of violence in teenage mothers. J Adolesc Health, 1999)

• 33.8% of births to unmarried teens younger than 16yrs resulted from statutory rape(Gessner BD, 1999)

• One-half of teens with rape histories resulting in pregnancy were raped more than once (Boyer D. Sexual abuse as a factor in teen pregnancy. Fam Plann Perspect.1992).

Violence and Teen Pregnancy

• The younger the partner the greater the partner gap. Over one-half of infants born to women younger than 18 yrs were fathered by adult men .

• 40% of 15 year -olds had partners aged 20 yrs or older. (Landry DJ. How old are US fathers? Fam Plann Perspect.1995)

• 74% girls who have had intercourse before 14yrs, reported having sex against their will (The Alan Guttmacher Institute,1994)

Violence and Teen Pregnancy

• Coercive sex is frequently perpetrated by boyfriends. 53% of nonfamilial perpetrators were adolescent girls’ boyfriends, dates,friends (Gershenon HP.The prevalence of coercive sex among teenage mothers. J Interpers Viol.1989.

• 51% of girls had their first coercive act between 13-16 yrs (Erickson PI. Unwanted sexual experiences among high school youth. J of Adol Health.1991.

Domestic Violence and Children

• Children are involved in 60 percent of domestic violence cases. More than three million children witness acts of domestic violence each year.

• Up to 50 percent of all homeless women and children in this country are fleeing domestic violence.

• More than 53 percent of male abusers beat their children

Domestic Violence and Children

• One in ten calls made to alert police of domestic violence is placed by a child in the home.

• One of every three abused children becomes an adult abuser or victim.

• Nearly 1/3 of children who witness the battering of their mothers demonstrate significant behavioral and emotional problems.

Definition- Domestic Violence/Abuse

• Domestic Violence-Injury to another within the context of family or intimate relationship

• Domestic Abuse-Forceful controlling behavior that coerces the victim to do what the abuser wants

Types of Abuse

• Physical-pushing, shoving

• Psychological-ignoring, controlling, criticizing

• Sexual-touching,calling with sexual names

Risks Factors for Violence during Adolescence

• Media

• Drugs/Alcohol

• Access to Firearms

• Lack of Self-Esteem

• Peer Group/School Influences

• Lack of Family Support

Risk Factors for Domestic Violence In Adolescence

• Commitment to relationship

• Fear of retaliation

• No place to go

• Fear of living alone

• Economic dependence

• Belief that they are responsible

• Hope that perpetrator will change

Signs/Symptoms of Abuse among Pregnant Teens

• Frequent somatic complaints (headaches, insomnia)

• Anxiety,irritability,crying

• Repeated visits to the ER

• Hx of being “accident prone”

• Injuries to breasts/abdomen

• Hesitancy to provide info on injuries (Often accompanied by partner who will prevent victim from answering directly)

• Anti-social behavior

• Foreshortened sense of future

Signs/Symptoms among Children(in abusive homes)

• Infants- FTT, developmental delays

• Toddlers-eating/developmental disturbances, clinging

• School age-increased physical complaints, decreased attention, behavior disorders

Complications of Abuse during Pregnancy

• Poor maternal weight gain

• Infection

• Anemia

• Increased second and third- trimester bleeding

• Miscarriage/Abortion

Barriers to Screening

• Lack of provider recognition

• Provider discomfort

• Fear of offending patient

• Time constraints

• Feeling of powerlessness in the area of treatment

Importance of Screening

• 90% of female patients feel their provider can help!

• 78% favor universal inquiry about physical/sexual assault

• 1 out of 4 women using ER’s revealed a history of partner violence when questioned

• 10-40% of women disclose abuse when screened by primary care providers

• 31% of mothers disclosed partner violence when asked by their pediatrician (Mcnutt LA. Reproductive violence screening in primary care. J Am Med Womens Assoc.1999)

Setting the Stage

• Discuss confidentiality

• Use clear language, avoid medical terms

• Remain non-judgemental

• Avoid talking down

• Encourage discussion, use open-ended questions

• Listen to the patient!

Screening for Domestic Violence Risks

• Has anyone close to you ever threatened to hurt you?

• Has anyone ever hit, kicked, punched or hurt you physically?

• Has anyone, including your partner, ever forced to have sex against your will?

• Are you ever afraid of your partner?

Domestic Violence Counseling

• Implement universal screening

• Acknowledge trauma

• Assess immediate safety

• Help establish a safety plan

• Offer educational materials

• Document interaction (including photos)

• provide ongoing support

• Offer list of community resources

• Provide referrals

Summary

• Screen: Adolescent mothers for domestic violence risks (at prenatal visit, interval checkups, postpartum visit, and well-baby exams)

• Ask: Are you ever afraid of your partner? Has anyone close to you threatened you? Hit you ? Forced sex against your will?

• Discuss: Safety plan, legal implications,trauma

• Provide: Documentation, as well as, information and referrals for community resources