Looking at Intimate Partner Violence (IPV) and Perinatal Depression (PD)

HRSA

Social Solutions InternationalMarch 6, 2012

2pm-3pm EST

Webinar Speakers and Guests

Moderator: Cara Finley, MPH Social Solutions International, Inc.

Keisher Highsmith, DrPHHRSA, Division of Healthy Start and Perinatal Services

Diana Cheng, MDMedical Director of Women’s Health, Maryland Department of Health and Mental Hygiene

Ifeyinwa Udo, DrPH (c), CPH Morgan State University & Johns Hopkins School of Nursing

Objectives

Discuss the intersection and effects of Intimate Partner Violence (IPV) and Perinatal Depression (PD)

Discuss IPV/PD screening Introduce the HRSA IPV/PD Toolkit for Healthy

Start Programs

INTERSECTION BETWEEN PERINATAL

DEPRESSION AND INTIMATE PARTNER

VIOLENCE

MARCH 6, 2012DIANA CHENG, M.D.

WOMEN’S HEALTHMARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE

DEFINITIONS

Perinatal Depression (PD)

Depression occurring During pregnancy Within the first postpartum

year

Intimate Partner Violence (IPV)

Pattern of assaultive or coercive behaviors perpetrated by a current or former intimate partner Physical Emotional Sexual

OVERLAP OF TYPES OF IPV

Emotional

Sexual

Physical

PREVALENCE OF RAPE, PHYSICAL VIOLENCE, AND/OR STALKING BY AN INTIMATE PARTNER,

U.S.

IPV Lifetime Females

Lifetime Males

Past Year Females

Past Year Males

Rape (sexual assault) 9.4 * 0.6 *

Physical violence 32.9 28.2 4.0 4.7

Stalking 10.7 2.1 2.8 0.5

Rape, physical violence and/or stalking

35.6 28.5 5.9 5.0

With IPV-related impact 28.8 9.9 * *

Needed medical care 7.9 1.6 * *

PTSD symptoms 22.3 4.7 * *

Concerned for safety 22.2 4.5 * *

Contracted STI 1.5 * * *Source: National Intimate Partner and Sexual Violence Survey, 2011

One out of every three American women will experience IPV in her lifetime.

Source: National Intimate Partner and Sexual Violence Survey, 2011

IPV accounts for a significant cause of injuries and emergency room visits among women.

Source: US DOJ 2005IPV is a leading cause of female homicides.

Homicide is the leading cause of death during pregnancy and postpartum in Maryland

Source: Cheng, 2010

IPV PREVALENCE

DEPRESSION AND IPV ACROSS THE FEMALE LIFE COURSE

Highest prevalence=reproductive ages

What is the significance of pregnancy/postpartum?

BirthMenarche Menopause

Death

PD AND IPV: UNDER-RECOGNIZED

PD

Under-recognized Non-”medical” Isn’t this normal?

Under-diagnosed Poor screening/counseling Stigma

Under-treated Effects on fetus/infant Access to care

IPVUnder-recognized

Non-”medical” Isn’t this normal?

Under-diagnosed Poor screening/counseling Stigma

Under-treated Effect on family Access to care

PD AND IPV: PREVALENCE

PD

Prevalence varies 9-11% during pregnancy 7-13% 1st postpartum year As high as 20% in some studies

Confidence intervals are high High degree of uncertainty

Source: Agency for Health Care Research and Quality (AHRQ), 2005

Perinatal IPV

Prevalence varies 1-20% during pregnancy Depends on definition and

population studied 4-8% in most studies

Confidence intervals are high High degree of uncertainty

Source: JAMA 1996

PD

Previous history of PDMaternal age <25Unhappy about pregnancyMultiple stressors

Relationship, financial, traumatic

Cigarette smokingBinge drinkingHistory of IPV

Perinatal IPV

Previous history of IPVMaternal age <25Unhappy about pregnancyMultiple stressors

Relationship, financial, traumatic

Cigarette smokingBinge drinkingHistory of depression

FACTORS ASSOCIATED WITH PD AND IPV,MARYLAND PRAMS DATA

Source: Maryland PRAMS

PD AND IPV: WHO IS HIGH RISK???

Depression

Occurs among all demographic groups socio-economic culture race religion sexual orientation education gender

Female >>male

IPV

Occurs among all demographic groups socio-economic culture race religion sexual orientation education gender

Female >>male

PD

Majority of women do not mind being asked about PD 80% comfortable with

screeningSource: Buist 2006

Majority of women are not asked about PD <50% are screened 22% used validated toolSource: Seehusen 2005

IPV

Majority of women do not mind being asked about IPV 90% comfortable with

screeningSource: Zeitler 2005

Majority of women are not asked about IPV 10% reported screening by

ob/gynsSource: Rodriguez 1999

PD AND IPV: UNIVERSAL ASSESSMENT

POSTPARTUM DEPRESSION: IMPACT OF ABUSE DURING PREGNANCY MARYLAND PRAMS, 2004-2008

Depression was reported by women who were:Physically abused (39%)Threatened or made to feel unsafe (35%)Felt daily activities were controlled (36%)Frightened for safety of family (33%)Forced to take part in sexual activity (31%)The prevalence of postpartum depression by IPV during

pregnancy was 34.6% compared to 11.9% without IPV.

POSTPARTUM DEPRESSION AND UNHEALTHY FACTORS,

MARYLAND PRAMS 2004-2008

Postpartum depression was reported by women 39% of women who were physically abused during

pregnancy37% of women who were binge drinking during

pregnancy

POSTPARTUM DEPRESSION (PPD) AND STRESSORS

PPD was reported by 39% of women who were physically abused during the year before delivery.

PERINATAL PHYSICAL ABUSE AND UNHEALTHY FACTORS

Physical abuse before or during pregnancy was reported by:17% of women with PPD 17% of women who smoked during pregnancy16% of women with no prenatal care

PERINATAL PHYSICAL ABUSE AND STRESSORS

Physical abuse before or during pregnancy was reported by:30% of women who were divorced or separated in the

year before delivery29% of women whose partners did not want the

pregnancy20% of women whose partners lost their jobs or were in

jail16% of women who were homeless

OVERLAP OF PD AND PERINATAL IPV

IPV PD

AFFORDABLE CARE ACT

As of 9/23/10, requires health insurers, including Medicare, to offer certain preventive health services free of co-pays for new health plans Depression screening, alcohol abuse screening/counseling, tobacco

cessation, STI prevention screening/counseling for those at high risk Institute of Medicine Clinical Preventive Services for Women, 7/2011,

recommendation for women and adolescent girls Screening/counseling for interpersonal/domestic violence in a culturally

sensitive and supportive mannerDHHS Secretary Sibelius

Starting in first plan year after 8/2012 [for many plans, starting 1/2013], complete insurance coverage without copays IPV/DV, contraception methods, STI counseling, well woman visits

ACOG COMMITTEE OPINION 2012

“Number 518, February 2012

Committee on Health Care for Underserved Women This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Intimate Partner Violence

Assess all women at 1st prenatal visit, each trimester and postpartum.”

INTERSECTION BETWEEN PD AND IPV

SUMMARYUnder-recognized, under-diagnosed, and undertreatedPrevalence

All demographic groups affected Age <25 Wide confidence intervals in different studies, 5-20%

Associated with stressors, smoking, alcohol use, unwanted pregnancy Co-morbidity of PD and IPV

Preventable Women don’t mind being screened Resources [treatment, services] available to help women Impact on maternal and child health can therefore be prevented

Ifeyinwa Udo DrPH(c), CPHMorgan State University School of Community Health/ Johns Hopkins

University School of Nursing

Definition of IPV Physical, sexual or psychological harm

By current or former partner or spouse

Younger women, separated or divorced, less educated, perinatal period are at increased risk

Perinatal Depression (PD)Major and minor episodes during pregnancy(antenatal)

And /or within 1st 12 months after delivery(postpartum)

Prevalence: 20% (antenatal), 12-16% (postnatal)

Up to 12% of every pregnant & postpartum women experience depression per year Prevalence doubled for low income women

(Leung & Kaplan, 2008; Earls et al., 2010)

Study 1-Depression during pregnancyObjective: Study the prevalence and risk factors associated

with depression during pregnancyCountry: South AfricaParticipants-1062 pregnant women, 18 & overDepression- measured using Edinburg Postnatal Depression

ScaleMode of data collection: InterviewHartley et al(2011)-Depressed mood in pregnancy:

Prevalence and correlates in two Cape Town peri-urban settlements

Study 1 MeasurementsOther measurements: Agesocial support alcohol and cigarette use during pregnancySocial supportParityEducationRelationship violence in the previous year

Study 1 Results• Results

Women who reported previous year partner violence were more likely to experience PD as compared to women who did not experience past year violence

Other risk factors include age, income, and support

Study 2-Depression during and after pregnancy• Objectives:

Assess impact of IPV on the course of perinatal depression; Taking into consideration, the effects of protective and risk

factors ;4 time periods from pregnancy-13 months post partum

• Country: U.S(LA)

• Participants:210 Latina pregnant women(IPV vs. No IPV group)

• Rodriguez et al.(2010)- Intimate Partner Violence and Maternal Depression During the Perinatal : A Longitudinal Investigation of Latinas

Study 2 Data CollectionMode of data collection: Interviews during

pregnancy, 3, 7, & 13 months postpartum

Depression: Measured using the Beck Inventory Fast Screen

IPV: Measured with the Abuse Assessment Screen

Study 2 MeasurementsOther measurements:AgeBirth placeIncomeEmploymentParityEducationPartner status

Study 2 Results• Results• For IPV and Non-IPV group

Prenatal and Postnatal depressionHighest Depression in prenatal periodLowest 3 months after delivery

• For IPV group(Vs. Non IPV) Significantly higher depression scores at each time points

(at or above cut-off)Higher cases of persistent depression(scores higher than

cut-off at >2 of the 4 time points)

PD can also happen after child birth

Study 3-Postpartum DepressionObjective: To Explore

The relationship between IPV during pregnancy and health outcomes for the mother and child post partum

Country: U.S (20 Cities)Participants: 3691mothersMode of data collection: Interviews(at delivery and

15 months post-partum)

McMahon, et.al (2011)

Study 3 MeasurementsOther measurementsRaceAgeEducationRelationship statusFamily structureParity

Study 3 ResultsResults physical & emotional victimization significantly increased the

likelihood of depression at 15 months follow-up

Depression scores higher for women who experienced physical victimization alone and those who experienced a combination of physical and emotional

Depression scores lowest in those who experienced emotional victimization alone

Study 3 Continued• Other factors:Married women were less likely to develop

depressionWomen having their first birth were less likely

ConclusionIPV is a great public health problemIPV is associated with depression before, during and

after pregnancyWomen depressed during pregnancy enter prenatal

care lateDepression during pregnancy negatively impacts

attachment between mother and fetus and /or infant Lead to problems cognitive, social, psychological and behavioral development of the child

McMahon, et.al (2011)

IPV/PD Resource Development Project and Toolkit

Cara Finley, MPH

Social Solutions International, Inc.

Activities – IPV/PD Project

1. A noted need to address the intersection of IPV and PD.

2. EWG Meeting #1

3. Literature Review

4. Needs Assessment

5. EWG Meeting #2

6. Strategic Planning and Toolkit Development

7. Piloting of Toolkit with Healthy Start

An Integrated Tiered Approach

PARTNERSHIPS- Focus on reaching out to partners with existing resources and best practices. Assist HS programs in reaching out and building partnerships within their community.

RAISE AWARENESS- Focus on raising awareness about the intersection of IPV/PPD and the importance of streamlined recognition, response and referral. Focus on providing data and support for the need to address IPV/PPD. Incorporate culturally appropriate materials and use a participatory approach.

TRAINING OF HEALTHY START STAFF- Focus on introducing HS to the new Core Competencies (including cultural competence), introducing and training staff regarding best practices/resources/curriculums and how to navigate, use and adapt for their program. Assist with implementation and strategies for sustainability.

RECOMMENDATIONS FOR POLICY CHANGE- Focus on developing Core Competencies and making recommendations to HRSA/Healthy Start for policy changes to incorporate into HS requirements. Use a participatory approach, keeping in mind culturally competent strategies.

IDENTIFY BEST PRACTICES AND EXISTING RESOURCES –Focus on identifying

and narrowing down best practices, existing resources and existing curriculums.

Tiered Approach Process

Contextual factors influence the work/the activities, and the work we do will in turn influence the contextual factors.

The factors listed relate to challenges identified over the course of the needs assessment including: stigma, belief that there was no intersection of IPV/PD, cultural challenges, limited funding and resources, competing priorities, and lack of leadership support.

Goals: To improve the health and safety of families experiencing intimate partner violence (IPV) and perinatal (PD).

To create new resources to assist Healthy Start (HS) programs in addressing the co-morbidities of IPV and PD.

Inputs: Staff (HRSA, SSi/Altarum, Healthy Start); Partners; EWG; HS Staff; HS clients; Funding; Time; Best Practices; Existing Resources; Webinar technology

Tiered Approach Process, cont.

Activities: Research/identify best practices and existing resources; Create policy recommendations; Introduce and train HS staff on new Core Competencies and Resources; Raise awareness, reduce stigma, build confidence among HS staff, leadership and clients; Assist HS in how to build and sustain effective partnerships

Short Term Outcomes: To increase knowledge and awareness of IPV/PD co-morbidities among HS staff and clients; To reduce stigma associated with IPV/PD among staff and clients; To motivate staff and clients to address IPV/PD; To highlight the need to provide services in a culturally competent manner

Intermediate Outcomes: To change HS policy to include concrete recommendations about IPV/PD screening, response and referral; To identify best practices and introduce/assist HS sites in adapting and implementing best practices; To increase confidence and improve the way HS staff respond to and address IPV/PD

Long Term Impact: To improve the health and safety of families experiencing IPV/PD; To improve the way HS programs are able to address IPV/PD in a culturally and linguistically appropriate manner; To reduce the incidence and prevalence of IPV/PD co-occurrence in HS sites.

Toolkit Goals

• Provide a guide that is culturally and linguistically appropriate to support community-based programs with making the case for why it is important to address the IPV/PD intersection

• Assist communities in reducing stigma and provide strategies for building partnerships and increasing support from leadership

• To improve the health and safety of families experiencing IPV and PD

Toolkit Contents

Assessing if You are Ready Making the Case Raising Awareness/Advocacy Cultural Competency Building and Sustaining Partnerships Policy and Legislation Standards of Care

Questions or Comments?

Contact Information:

Keisher Highsmith, DrPH khighsmith@hrsa.gov

Cara Finley, MPH cfinley@socialsolutions.biz

Phone: 202-870-2226