IPV

- A sweet young couple are laboring nicely for hours, until the husband leaves the room to go to the bathroom, whereupon, the woman clutches my hand, and pleads with me in a desperate whisper, "Please help me, he's threatening to take my baby from me."
-A refugee woman is slapped and pulled from the bed by her hair by her husband, just hours after giving birth.
-A young woman labors all night with premature labor, induced by a kick to the abdomen she received from her boyfriend. Though the baby is rushed to a high level neonatal intensive care nursery, he dies early the next morning.

These are just a few of the cases of Intimate Partner Violence I saw personally during my stint as a labor and delivery nurse. One of the things I found most shocking about my job, was how often I would interface with violence. It was not something I expected to encounter as a labor nurse. I quickly learned that if I was going to work with women, I was going to encounter occurrences of violence.

Intimate partner violence is defined as: violence that occurs between a victim and perpetrator who are current or former spouses or partners. The Center for Disease Control (CDC) recognizes four types of intimate partner violence:

1. physical violence-the intentional use of force involving hitting, punching, kicking, etc.
   
2. sexual violence-the actual or threatened use of force to compel a person to submit to sexual acts against their will, attempted or completed sex acts with a person unable to avoid participation, communicate unwillingness, or understand the nature of the act, and finally, abusive sexual contact
   
3. threats of physical or sexual violence
4. emotional abuse-use of humiliation, name calling, deliberate embarrassment, controlling their activities, isolating from family and friends, controlling or withholding resources including financial
5. coercive control and intimidation- acts perceived as threatening or violent
   

The CDC website declares that "all women are at risk'' of intimate partner violence no matter their socieconomic status, education level, age, religion, ethnic or racial group, etc. In other words folks, you can't tell by looking. My experience taught me that. My biases had me keeping an eye on the refugee women with their submissive social structures and missing completely the educated middle class couple with the controlling husband. To become better at detecting IVP and intervening with needed resources, I had to learn that no one is 'risked out' and that every woman in my care should be screened for domestic abuse.

For maternal and fetal health, the consequences of undetected IVP can be grave:
-miscarriage (less than 20 weeks gestation)
-infant injury or death from maternal trauma (more than 20 weeks gestation)
-maternal stress and depression
-self medicating with smoking, drug use, alcohol (all linked to poor infant outcomes)
-decreased or delayed prenatal care (also linked to poor outcomes)
-maternal injury and death
-child abuse or children witnessing abuse

Unfortunately the cost of intimate partner violence doesn't stop there. The Women's, Infants, and Children's Health Committee that I co-chair recently published a report on the literal costs of domestic violence in our city. A 'point in time' survey was sent out to law enforcement, healthcare agencies, shelters, the courts and other agencies to determine the services and fees provided related to domestic violence in a 24 hour period. The total estimated costs of domestic violence for one day in our city was $61,000, or an estimated 2 million dollars a year! About 94% of the funding was provided in services to victims, the other 6% in perpetrator expenses. Of those receiving services for violence, about 6% were pregnant. This cost of IPV snapshot was quite eyeopening.

When I attended the obstetrical complications workshop last week, Ms. Otemba reviewed the following information important for nurses who are on the front lines of assessing for IVP.

Cues to IVP
- delayed prenatal care
-noncompliance to therapeutic regimens
-frequent ER visits
-controlling partner
-somatic complaints (headaches, pain, fatigue, stress)
-fearful, evasive affect
-characteristic injury pattern (head and neck, torso, different stages of healing)

Assessment
Appropriate assessment means universal screening for every patient. Let the patient know that you ask every patient these questions and they should be asked in private without any family members presents.
"Within the year, have you been hit, slapped, kicked or otherwise physically hurt by someone? Since you've become pregnant? Has anyone forced you to have sexual activities?"

While these questions are appropriate to ask every patient, to get patient disclosure we have to create an environment where it is safe to disclose. Privacy, brevity (the abuser may be lurking near by), trustworthiness, nonjudgmental attitude, acceptance are all a part of what we have to offer patients in order to facilitate disclosure. Most healthcare providers may have discomfort asking these questions, or may not know what to do if the answer is yes. It is important to have a plan.

Supportive Intervention

You ask your patient with suspicious injuries if she has been beaten, and she answers, 'yes'. Now what?

-Emergency management: It's imperative to know your community resources. Here in my city, we have the Bridge SPAN (Safe Patient Advocacy Network) program. Our local shelters work closely with the hospitals so that through Bridge, with just a phone call from the nurse (or any staff member) a shelter counselor will be dispatched to the hospital 24/7 to offer shelter, police protection, orders of protection, counseling, case management, and child protection and other needed emergency services.
-Validation: "You do not deserve to be afraid, controlled, threatened, or hurt." The patient may need repetitive validation to understand that it was not her/his fault and that they do not deserve such treatment.
-Evaluate the severity: There are many tools available. In our area, agencies are encouraged to use the Lethality Assessment Program to determine the level of danger a patient might be in. This will help to determine the appropriate interventions.
-Education: often control has been establish by lies and deceit. Patients need to know the facts about their situation and what their rights really are.
-Referrals to ongoing community care and support such as legal services and support groups.

Recently, I met with a woman who has left an abusive relationship after many years. Her abuse was revealed to me during care provided for one of her pregnancies. When she felt it was safe to do so, she planned an escape that was two years in the making. When the opportunity came to flee safely, she took her children and left, with a well executed plan in place. They have remained safe from their abuser for a number of years. Talking with her about her situation reminded me, that there is hope for a life beyond the violence, if we are all willing to do our part.


Center for Disease Control: Intimate Partner Violence in Pregnancy. Retrieved 11/8/10. http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/sld001.htm#10

Otemba, J. (2010). Complicated Pregnancies; implications and management. PESI healthcare. Workshop presented on 11/5/10 in Lenexa KS.

Kansas City Health Commission. Estimating the costs of domestic violence in the Kansas City area: a report on the 2009 domestic violence, point in time survey for the greater Kansas City area. Women's, Infant's, and Children's Health Committee, and the intimate Partner Violence Subcommittee. Approved and issued on 10/1/2010.