Intimate Partner Violence Screening

Fact Sheet and Resources

Nearly 1 in 6 pregnant women in the U.S. have been abused by a partner.

Women who experience intimate partner violence prior to and during pregnancy are at increased risk of low maternal weight gains, infections, high blood pressure and are more likely to deliver pre-term or low birth weight babies.

Women who received prenatal counseling for IPV had fewer recurrent episodes of IPV during and post pregnancy, as well as better birth outcomes such as lower rates of preterm birth and low birth weight.

U.S. Preventive Services Task Force (USPSTF) Grade: B
USPSTF Recommendation:
Screen women of childbearing age for intimate partner violence (IPV), such as domestic violence (DV), and provide or refer women who screen positive to intervention services. This recommendation applies to women who do not have signs or symptoms of abuse.¹

Intimate Partner Violence - Provider Fact Sheet    PDF - 77.96 KB

• Why is this important?
• How frequently is this preventive service being provided?
• What are the best screening practices identified in the literature?
• What are the best interventions identified in the literature?
• What barriers exist for providers?
• What are some provider-driven ideas to address these barriers?
• What does the Affordable Care Act cover?
• What does Medicaid cover?
• References

For More Information

• Provider Implementation Tools
• Other Resources

Why is this important?

According to the CDC, it is estimated that roughly 1.5 million women are raped and/or physically assaulted each year in the United States.²

Intimate partner violence (IPV) affects as many as 324,000 pregnant women each year.³

Physical violence perpetrated by intimate partners is also often accompanied by emotionally abusive and controlling behavior.⁴ Although women of all ages may experience IPV, it is most prevalent among women of reproductive age and contributes to gynecologic disorders, pregnancy complications, unintended pregnancy, and sexually transmitted infections.⁵

Due to underreporting and lack of recognition, IPV may occur more commonly among pregnant women than conditions for which they are currently being screened (i.e. gestational diabetes, preeclampsia, etc.). IPV can have direct and indirect impacts on fetal health, such as spontaneous abortion and maternal stress, which in turn can induce alcohol or drug use or smoking. These behaviors are associated with poor outcomes like low birth weight, fetal alcohol syndrome, and others. Three studies have also found possible associations between IPV and unintended pregnancies.

Research has found that IPV rates are highest in families with young children, which supports intervention during the pre and perinatal periods.⁶ Screening is effective in the early detection and effectiveness of interventions to increase the safety of abused women.⁷

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How frequently is this preventive service being provided?

Ninety-six percent of women receive prenatal care, which can consist of 12-13 prenatal visits. As such, it can be an important window of opportunity to screen.⁸ Although screening for IPV is recommended by the USPSTF, studies have shown very low screening rates ranging from 1.5%- 12% in primary care settings.⁹

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What are the best screening practices identified in the literature?

American Congress of Obstetricians and Gynecologists (ACOG), in line with the U.S. United States Department of Health and Human Services (HHS) and Institute of Medicine (IOM), recommends that IPV screening and counseling should be a core part of women's preventive health visits and at periodic intervals, including obstetric care (at first prenatal visit, at least once per trimester, and at the postpartum checkup, as disclosure may not occur at the first attempt). Providers should also offer ongoing support, and review available prevention and referral options.¹⁰

All of the screening tools evaluated by the USPSTF are directed at patients and can be self-administered or used in a clinician interview format. The 6 tools that showed the most sensitivity and specificity were:¹¹

• HITS (Hurt, Insult, Threaten, Scream) [PDF]
• OVAT (Ingoing Violence Assessment Tool) [PDF]
• STaT (Slapped, Things and Threaten) [PDF]
• HARK (Humiliation, Afraid, Rape, Kick)
• CTQ–SF (Modified Childhood Trauma Questionnaire–Short Form)
• WAST (Woman Abuse Screen Tool) [PDF]

Other screening tools for pregnant women include 4 Ps¹² and the Abuse Assessment Screen [PDF]. CDC has compiled a comprehensive list of screening instruments [PDF] that have been tested on various patient populations.

Studies have shown that patient self–administered or computerized screenings are as effective as clinician interviewing in terms of disclosure, comfort, and time spent screening.¹³

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What are the best interventions identified in the literature?

Evidence from randomized trials support a variety of interventions for women of childbearing age, including counseling, home visits, and mentoring support. Depending on the type of intervention, these services may be provided by clinicians, nurses, social workers, non–clinician mentors, or community workers. Counseling generally includes information on safety behaviors and community resources. In addition to counseling, home visits may include emotional support, education on problem–solving strategies, and parenting support.¹⁴

A systematic review that evaluated the benefits of IPV interventions in primary health settings showed that 76% of interventions resulted in at least one statistically significant benefit – reductions of violence, improvement of physical and emotional health, safety promoting behaviors, use of IPV community based resources. It also highlighted the following domains of successful interventions: focusing on self–efficacy and empowerment, focusing on access to IPV resources, and brief non–physician interventions (collaborative multidisciplinary care teams).¹⁵

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What barriers exist for providers?

• Time constraints
• Discomfort with the topic
• Fear of offending the patient or partner
• Need for privacy
• Perceived lack of power to change the problem, and
• A misconception regarding patient population's risk of exposure to IPV¹⁶

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What are some provider-driven ideas to address these barriers?

• Massachusetts Medical Community's "Use your RADAR" approach provides a thorough step–by–step resource in how to have an effective conversation about IPV with patients and develop appropriate referral networks to ensure continuity of care for patients who screen positive.
• Providers can play a significant role: creating and maintaining trust relationships with patients and being supportive is key to women disclosing sensitive information. Providers can inform a patient that IPV is prevalent and has serious health consequences, which is better than just providing information on resources, but may not be better than doing nothing.
• Many women do not feel comfortable disclosing IPV; by providing education and resources, she can still receive the information and use it when it is most appropriate for her. Also, discussing safe and healthy relationships is important and can prevent serious abuse from occurring later on.

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What does the Affordable Care Act cover?

All Marketplace plans and many other plans must cover domestic and interpersonal violence screening and counseling for all women without charging a copayment or coinsurance. This is true even if the patient has not met their yearly deductible. This applies only when these services are delivered by a network provider.¹⁷

The Centers for Medicare and Medicaid Services (CMS) also provides information about the Coverage of Preventive Services.

HealthCare.gov provides lists of preventive care benefits for all adults and those specific to women.

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What does Medicaid cover?

Each state has its own plan for Medicaid coverage. To find out more about Medicaid and CHIP eligibility and coverage in your state, please visit Medicaid.gov.

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For more information

Provider Implementation Tools

Intimate Partner Violence During Pregnancy, A Guide for Clinicians
The American College of Obstetricians and Gynecologists (ACOG)/Centers for Disease Control and Prevention (CDC) screen show on intimate partner violence during pregnancy is a training tool for clinicians to increase understanding of the important role they can play in identifying, preventing, and reducing intimate partner violence.

Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings [PDF] is a compilation of existing tools for assessing intimate partner violence (IPV) and sexual violence (SV) victimization in clinical/healthcare settings. This document should serve as a guide to aid in the selection of assessment instruments for use in health care settings to identify victims requiring additional services. The identification can help practitioners make appropriate referrals for both victims and perpetrators.

Futures Without Violence provides index of health and domestic violence related materials, including Affordable Care Act guidelines for screening and a guide for Addressing Intimate Partner Violence in Obstetric, Gynecologic and Reproductive Health Care Settings.

Health Cares About IPV: Intimate Partner Violence Screening and Counseling Toolkit offers providers, health plan administrators, domestic violence advocates and others, the tools to implement the recommendations and identify and support patients facing abuse.

Maryland Department of Health and Mental Hygiene, IPV Information for Healthcare Providers [PDF] includes a guide for providers, a sample assessment tool, and methods to best dialogue with patients.

The Danger Assessment helps to determine the level of danger an abused woman has of being killed by her intimate partner.

The National Health Collaborative on Violence and Abuse list of recommended Preventive Medicine Service Codes [PDF] to Record Screening and Brief Counseling of Domestic and Interpersonal Violence (updated September 2013).

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Other Resources

How the Affordable Care Act benefits survivors of domestic violence [PDF] provides information on The Affordable Care Act & Women's Health from the HHS Administration for Children and Families (ACF) Division of Family Violence Prevention and Services (December 2013).

Health Resources and Services Administration (HRSA) Intimate Partner Violence and Perinatal Depression website provides a comprehensive approach for community-based programs to address intimate partner violence and perinatal depression.

March of Dimes Abuse During Pregnancy: A Protocol for Prevention and Intervention [PPT]

CDC Intimate Partner Violence website provides a variety of information including definitions and data, risk and protective factors, consequences, prevention strategies, and additional resources.

CDC Violence and Reproductive Health website provides background information on key activities related to violence and reproductive health. Federal and other programs are highlighted as they may be important to public health professionals concerned about preventing violence that is associated with pregnancy-related illness, injury, and death.

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