Abuse During Pregnancy: A Protocol for Prevention and Intervention, 3 rd Edition Judith McFarlane,...

Abuse During Pregnancy:

A Protocol for Prevention and

Intervention, 3rd Edition

Judith McFarlane, RN, DrPH, FAANBarbara Parker, RN, PhD, FAAN

Barbara Moran, PhD, MPH, CNM, FACCE

© 2006, March of Dimes

A Woman’s StoryAbused women must be allowed to make their own decisions in their own time. Although extremely difficult to detail, some of the complexities and dangers experienced by an abused woman and the perceptions of those who try to support her are summarized in A Woman’s Story on the inside front cover of the module. Read and discuss the story.


Violence Against Women in the U.S.• Intimate partner violence accounts

for 22% of all violent crimes against women (Rennison & Welchans, 2003).

• 25% of women have experienced partner violence at least once (Tjaden & Thoennes, 2000).


Extent and Costs of Violence Against Women• 5.3 million partner victimizations

against women occur each year in the U.S. resulting in nearly 2 million injuries and 1,300 deaths (CDC, 2003).

• The cost of IPV exceeds $5.8 billion, including $4.1 billion in direct medical and mental health care and nearly $1.8 billion in indirect costs of lost productivity (CDC, 2003).


Abuse During Pregnancy• Between 3.9% and 8.3% of women

are abused during pregnancy (Gazmararian et al., 1996).

• Using these statistics for the approximately 4 million women in the U.S. who gave birth in 2004, we can expect 156,000 to 332,000 experienced abuse during pregnancy.


Sexual Assault• Sexual abuse occurs concurrently

with physical abuse for many women.• In a 2005 study, 68% of physically

abused women also reported sexual assault within the past 90 days. When these same women were asked about the sequence of physical and sexual abuse, 30% reported that the sexual abuse preceded physical abuse (McFarlane et al., 2005).


Abuse Affects Maternal Physical HealthPhysical abuse before, during and after pregnancy is associated with:

– Higher incidence of STIs such as bacterial vaginosis, chlamydia trachomatis and HIV

– Urinary tract infections and pyelonephritis


Abuse Affects Maternal Mental HealthWomen abused during pregnancy

report:– Higher alcohol and illicit drug use – More depression, anxiety, isolation– Less social support– Lower self-esteem– More suicidality


Abuse Affects Infant BirthweightWomen who report physical, sexual or emotional abuse during pregnancy are more likely than nonabused women to give birth to a LBW child (Murphy et al., 2001).


Abuse During Pregnancy: MurderStatewide analysis of death certificates in North Carolina and Maryland found that murder was the leading cause of death among pregnant or recently pregnant women. In contrast, murder was the fifth leading cause of death among nonpregnant women during the same time period (Horton & Cheng, 2001; Parsons & Harper, 1999).


Severity of Abuse and Pregnancy• Pregnant women report more

frequent and more severe abuse compared with women abused before pregnancy but not during pregnancy (McFarlane et al., 1995).

• The risk of becoming an attempted or completed femicide victim is 3-fold higher for women abused during pregnancy

(McFarlane et al., 2002a).


Abuse and Unintended Pregnancy

• An estimated 3 million unintended pregnancies occur annually in the U.S. (Stewart, Trussell & Van Look, 2004). Many are the result of rape or sexual abuse.

• The national rape-related pregnancy rate is about 5% (Holmes et al., 1996).

• Upwards to 20% of abused women report a rape-related pregnancy, a rate 4 times the national rate (McFarlane et al., 2005).


Emergency Contraception• Levonorgestrel (Plan B) is an emergency

contraceptive product approved for use in the U.S.

• Plan B reduces the risk of pregnancy after unprotected intercourse by 89% when taken within 120 hours after unprotected inter-

course (Stewart, Trussell & VanLook, 2004).

• Emergency contraception could prevent as

many as 1.5 million unintended

pregnancies in the U.S. (Stewart, Trussell & Van Look, 2004).


Abuse Assessment for Pregnant Women• Abuse assessment has the potential

to disrupt the victimization process as the questions directly intrude on the private nature of victimization.

• The health care provider forwards the idea that abuse is not normal and that help is available.

• Disclosure of abuse ends the secrecy and privatization of the violent relationship.


Acceptability of Abuse Assessment to Women• Women are willing to discuss abuse

with their health provider and see positive benefit from doing so (Gielen et

al., 2000). • An emerging literature notes the

missed opportunities for potentially life-saving interventions that abuse assessment in health care settings might provide (Sharps et al., 2001).


The Process of Abuse Assessment• The first task of assessment is for

providers to examine their own feelings and beliefs about abuse.

• Physical abuse has long been minimized:– “It was only a slap” diminishes it. – “She is impossible” justifies it. – “Spare the rod and spoil the child”

condones it. – “I just don’t believe it happens, certainly

not during pregnancy” denies it.


Pause to Ponder

• What comments have you heard that minimize abuse, justify abuse and deny abuse?

• What was the setting when the comments were made?

• How did people respond to the comments?


Assess the Chart for Signs of AbuseChart information that may indicate

abuse:– Previous assault: A man who hits a

woman before pregnancy is likely to hit her during pregnancy

– Injuries consistent with assault: • • • Bruises to the upper arm, neck and face• Breast and genital mutilation • Mouth and dental trauma

• Teeth marks • Burns • Missing clumps of hair • Bruises on the pregnant abdomen• History of broken bones


Assess the Chart for Signs of Abuse (Continued)

– History of depression, substance use, suicide attempts

– Multiple medical visits for injuries or anxiety symptoms

– Repeated visits for somatic complaints including headaches, insomnia, back, chest or pelvic pain

– Eating disorders– Tranquilizer or sedative use


Physical Exam Findings that May Indicate AbuseInformation obtained during physical examinations may signal abuse:

– Injuries consistent with assault not explained:

Bruises to the upper arm, neck and face Breast and genital mutilation Mouth and dental trauma

Teeth marks Burns Missing clumps of hair Bruises on the pregnant abdomen


Physical Exam Findings that May Indicate Abuse (Continued)

– Painful vaginal examination– Anxious behavior

•Crying, sighing•Minimizing statements•No eye contact (not applicable in

some cultures)•Depression


Assessing for Abuse• Provide a private and confidential

setting.• Always assess apart from the male

partner and any children.• In the few states with mandatory

reporting laws for spouse abuse, the provider should assure the woman that the abuse will not be reported to the police unless she wants it reported.


Abuse Assessment Questions• Read the Abuse Assessment Screen

questions (Figures 1 and 2) to the woman, positioning the piece of paper so she can see the questions as they are read.

• If the woman reports abuse, ask her to mark abused areas on the body map.

• Always maintain eye contact and always thank the woman for sharing.


Assessing for Danger• If the woman is abused, assess the

level of danger. Both the frequency and severity of abuse escalate over time, and the potential for a lethal outcome is a reality.

• Use the Danger Assessment (Figures 3 and 4) to assist a woman to objectively evaluate the safety of her relationship.


Sexual Abuse Assessment• All nursing assessments should

include questions about sexual abuse. Use broad questions -- “Has anyone forced you into sexual activities?”

• Interventions should be non-judgmental and should offer psychological support to the woman.


Documentation of AbuseDocument the abuse using a designated abuse assessment form such as the Abuse Assessment Screen.

– If no history or threat of abuse exists, document the absence of abuse and the community resource phone numbers and educational resource materials offered.


Documentation of Abuse (Continued)

– If abuse is reported, document:•The frequency and severity of past

and present abuse•The location and extent of injuries,

including any pain and disability days from work as a result of the abuse

•Treatments and interventions offered, including handouts, other educational materials and phone numbers for police and shelters


Intervention for Abuse: Safety Planning• Tables 6 and 7 provide a simple

handout to help abused women determine their safety options (McFarlane et al., 2002, 2004).

• Part of a safety plan is reviewing signs of increased danger along with options and safety behaviors.


Safety BehaviorsWhat would you suggest to an abused woman for:

– Hiding money, house and car keys – Establishing a code – Removing weapons– Securing social security numbers, rent

and utility receipts and marriage license


Intervention for AbuseStandard nursing action for abused women includes referral to criminal justice agencies, protection orders and police services (McFarlane et al., 2000).


Intervention for Abuse: Community ReferralsAn important intervention for all abused women is to identify and offer phone numbers and addresses for community resources for emergency help, shelter, counseling and legal aid.


Intervention for Abuse: Protection OrdersA protection order denotes a court order that restricts access of one person (the male abuser) to the person, property, children, family or live-in friends of another person (the abused woman for a specified time period.


Protection Orders and Future Abuse• McFarlane et al., 2004 measured the

effectiveness of civil protection orders toward reducing levels of intimate partner violence.

• Results showed significant reductions in physical assault, stalking, risk factors for murder, and work harassment, over time, among all women applying for a protection order, regardless of receipt .


Intervention for Abuse: Police ServicesContact with the police can deter future violence. When the police are contacted the abuse becomes public.


Intervention for Abuse: Shelter ServicesShelter services for abused women are available in every state and are an important source of temporary housing and counseling. The woman should contact the shelter before the next abusive episode and describe her situation.


Pregnant Abused Teenagers Brutin (1995) found 26% of pregnant teens reported physical abuse by their partners, and half of them reported that the abuse started or increased after the partner learned of the pregnancy.


Teen Dating Violence• Adolescents are particularly

vulnerable to dating violence. Between 15% and 40% of adolescents have experienced some form of date violence (Ackard & Neumark-Sztainer, 2002; Lewis & Fremouw, 2001).

• Among 9th through 12th grade high school students, one in five females reported being physically or sexually abused by a dating partner (Silverman et al., 2001).


Abused Women Living in Rural Areas• Women in rural areas are at greater

risk of experiencing abuse related to geographical isolation, communication difficulties, police response time and inadequate health care services (Websdale, 1995).

• Anonymity is a difficult problem for women living in rural areas and prevent the woman from seeking assistance.


Immigrant Women and Abuse• Studies of immigrants found that

stressors related to immigration, such as prejudice and lack of English proficiency, contribute to abuse and may act as barriers to help seeking (Loue & Faust, 1998; Perilla et al., 1994).

• Abused women are frequently prevented from learning English by the abuser, and lack of English proficiency prevents women from obtaining employment (Firestone et al., 1999).


Pause to Ponder• Consider how you would respond

to the following stories of abused women.

• Work in teams of two with one person being the abused woman and the other person the nurse.


How Do You Respond?

A Woman’s Words“My husband beat me during each pregnancy. He threw away the vitamins and would not let me go back to the clinic. He said I did not need the vitamins and medicine for infections. I was too scared to go to the emergency room. I knew the doctor or nurse would look at me and ask, ‘Why does she stay?’ All those kicks, all those beatings, all those falls—there was no one for me.”


How Do You Respond?A Woman’s Words“He’s always had a temper, especially when he’s doing drugs. But when I got pregnant, it got worse, because I didn’t want to do drugs with him because I was afraid taking drugs would hurt the baby. So he’d go off on his motorcycle with his buddies and not come home until he was half-crocked. We live in a trailer a long way from anyone, so there was no one to hear me when I screamed. Once I heard him coming back, and I took my daughter, and we tried to hide in the woods. He found us and dragged me back and threw me around the living room. The next thing I know he was kicking my belly. And he was wearing his biker boots.”


How Do You Respond?

A Woman’s Words“The kids and I are put out on the highway every morning at 6:00 with a sign asking for money. He watches from the car across the street. The kids cannot go to school, and we are all given one meal at the end of the day. I want to leave, but I do not have papers and do not speak English. He says if I try to leave, he will kill us. He sleeps with a machete under the bed.”


Contact is Success• Abuse of pregnant women is common

and associated with effects on maternal health and infant birthweight.

• Pregnancy may be the only time women come into frequent contact with health care providers. Simple, clinical assessment for abuse can reliably identify abused women and begin the intervention process.


Extending Your Understanding• What community resources for

abused women, including emergency shelter, legal aid, counseling and medical care, exist in your community?

• What requirements exist for use of community resources for abuse in your community?


Practice Your Understanding• Role play assessing a pregnant

client for abuse.• Role play forming a safety plan

with an abused pregnant woman.• Role play offering information on

options to an abused pregnant woman.


Discuss Your Feelings• How did the information in the

module make you feel?• How did the information change

the way you think about abuse of pregnant women?

• What changes in your nursing practice are indicated by the information you have learned?


CongratulationsYou have increased your understanding and skills for working with pregnant abused women to interrupt the abuse and promote the health and safety of women and their children.

Abuse During Pregnancy: A Protocol for Prevention and Intervention, 3 rd Edition Judith McFarlane,...

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