Dynamics of Interpersonal Violence and the Childbearing Experience

Dynamics of Interpersonal Violence and the Childbearing Experience: What Nurse-Midwives need to know Developed and compiled by Tara Cardinal, MN, CNM, ARNP

Objectives ۰ Describe 5 ways ۰ Identify 3 ways ۰ to support safety and effective help seeking in your patients Articulate 5 barriers ۰ ۰ to support a mother with a history of trauma anticipate potential triggers and cope Identify 3 resources ۰ IPV impacts maternal and neonatal physiology legal, health and/or social - to leaving abusive situation while pregnant Familiarize self with the Power and Control wheel Describe 2 guidelines or curriculum resources that will enhance your screening, counseling and response

Objectives ۰ Describe 5 ways ۰ Identify 3 ways ۰ to support safety and effective help seeking in your patients Articulate 5 barriers ۰ ۰ to support a mother with a history of trauma anticipate potential triggers and cope Identify 3 resources ۰ IPV impacts maternal and neonatal health legal, health and/or social - to leaving abusive situation while pregnant Familiarize self with the Power and Control wheel Describe 2 guidelines or curriculum resources that will enhance your screening, counseling and response

Acknowledgements ۰ Mentors: Sheila Capestany, Shannon Harris, Leigh Hofmeier, Lois Thetford ۰ Leaders in the field: Judith Mc. Farlane, Julia Seng, Jacquelyn Campbell, Kathleen Kendall-Tackett, Penny Simkin ۰ Organizations: WCSAP, WSCADV, BC Women’s Health Center

Acknowledging You ۰ Individual and collective Personal experience Professional experience Research endeavors

Trauma Informed Care ۰ Assessment and modification at all levels of an organization Ensure basic understanding of how trauma impacts whole person § § § Triggers and vulnerabilities Seeks to avoid re-traumatization Creating supportive services and work environments “Traumatic experiences can be dehumanizing, shocking or terrifying, singular or multiple compounding events over time, and often include betrayal of a trusted person or institution and a loss of safety. ” (SAMHSA, 2013)

Basic Premises ۰ Short and long-term psychological and physiological impacts on both a mother, her child, family, community and society ۰ Perinatal care providers close relationships Intersection at critical time Safe/respectful environment ۰ Effective interventions improve safety and outcomes ۰ Women as experts in own reality

A few caveats ۰ The topic is extremely complex, multifaceted with overlapping dimensions ۰ Uncoordinated approaches ۰ Research is fragmented ۰ Social and health services are fragmented ۰ Women’s perpetration of violence against their partners ۰ Minor focus on perpetration of violence

Definitions ۰ ۰ Intimate partner violence (IPV) vs. domestic violence (DV) IPV § Reproductive/sexual coercion § ۰ “Pattern of assaultative and coercive behaviors that may include inflected physical injury, psychological abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and threats… aimed at establishing control by one partner over the other. ” “…involves behaviors to maintain power and control in relationship related to reproductive health … behaviors that interfere with contraception use and/or pregnancy. ” × Birth control sabotage, pregnancy pressure and coercion, sexual coercion Variations making research difficult

Some of What We Know ۰ Greater frequency than other high-risk conditions ۰ Increased prevalence in economically disadvantaged communities and when higher margin of inequality § Highest prevalence in tribal communities ۰ “…Maternal depression may itself represent the first adverse life event to which one can be exposed. ” (Neigh, 2009)

Who, When & How Much? ۰ ۰ 1 in 4 women physically /sexually assaulted by current or former partner 40% teen moms experienced IPV 66% on public assistance disclosed birth control sabotage 3. 5 times more likely to become pregnant than non-abused Of those seeking abortions: ۰ ۰ ۰ § 3 times more likely victimized than women continuing pregnancy (FWV, 2012) 66% of murdered women known to have experienced violence beforehand (Plichta, 2005) Murder is the second most common cause of injury-related death for pregnant women (31%) after car accidents. (Chang et al. , 2005) 13 -24% pregnancy associated deaths due to homicide (Plichta, 2005)

Who, When & How Much? ۰ ۰ ۰ ۰ 13 -50% report abuse in pregnancy as the first episode Research shows it is dramatically underreported and not enough providers feel comfortable asking the questions. More common than gestational diabetes or preeclampsia One of the most common reasons for women and their children becoming homeless 66% of murdered women known to have experienced violence beforehand (Plichta, 2005) Murder is the second most common cause of injury-related death for pregnant women (31%) after car accidents. (Chang et al. , 2005) 13 -24% pregnancy associated deaths due to homicide (Plichta, 2005)

Who, When & How Much? ۰ Increased child abuse occurrence with DV, “ 30 -60% of perpetrators of IPV also abuse children in household. ” ۰ “Witnessing violence between one’s parents or caretakers is the strongest risk factor of transmitting violent behavior from one generation to the next. ”

Roots of Violence ۰ Socio-cultural Oppression § § Macro-Micro Colonialism-Bullying ۰ Epidemic of the disease ۰ Public health problem ۰ Eradication lies at the root § Clinical interventions reduce harm and decrease spread

Cycle of Overlapping Violence Socio-cultural-historical ? CHILDHOOD: Exposure to violence ADULT IPV BULLYING DATING VIOLENCE Dr. Claire Crooks, 2010

Intersection of Violence and Pregnancy ۰ For some, abuse may begin or escalate in pregnancy. ۰ For others, it may decrease of pause. ۰ Some women are more likely to leave because their pregnancy is a motivator for them ۰ It can also be a time of increased vulnerability where a woman may feel more dependent on her abuser (WA DOH, 2008)

Stages of Change dependent on: § § § Readiness for change Flexibility with changing context Resourceful but limited Tailored interventions Harm reduction × Transtheoretical Model of Change (Prochaska, Di. Clemente, & Norcross, 1992) × Haggerty & Goodman, 2003 Precontemplation Maintenance Action Contemplation Preparation

Stages of Change: Surviving Intimate Partner violence During and After Pregnancy by Alice Kramer, MS, RN (Kramer, 2007)

www. theduluthmodel. org

asafepassage. info Jodi Hall, Ph. D

Power and Control Male Privilege ۰ Demanding she care entirely for the infant and household ۰ Asserting that the child will be raised according to his customs and belief systems ۰ Demeaning her role as a mother

Power and Control Emotional Abuse ۰ Telling her she looks fat or making other derogatory comments about her changing body ۰ Verbally abusing her so she is unable to care for herself in pregnancy and postpartum ۰ Sabotaging her efforts to reduce or eliminate substances that may be harmful to herself or their developing baby

Power and Control Using Children ۰ Threatening to harm their child should she decide to leave ۰ Trying to convince others that she is an unfit mother ۰ Threatening to call child protection agencies

Power and Control Physical Abuse ۰ Increasing the severity/frequency of physical assaults ۰ Directing abuse towards her abdomen and or genitalia ۰ Forcing her or not allowing her to breastfeed

Power and Control Minimizing, Denying and Blame ۰ Holding her solely responsible for the pregnancy ۰ Refusing to admit that he is the father of the child ۰ Blaming her for the child being the “wrong” sex

Power and Control Sexual Abuse ۰ Forcing or causing an unwanted pregnancy through direct means (sexual assault) or indirect means (sabotaging contraception) ۰ Forcing her to engage in unwanted sexual activities during the pregnancy or too soon postpartum which could cause injuries ۰ Having an affair, transmitting STI’s to her, causing risk to her and the fetus

Power and Control Coercion and Threats ۰ Threatening to leave her if she doesn’t have the child ۰ Threatening to harm her if she tells any of her caregivers about the abuse ۰ Threatening to cause injury to their unborn baby

Power and Control Financial Abuse ۰ Denying access to adequate food to support a healthy pregnancy ۰ Making her work despite concerns for health ۰ Refusing to pay for child related expenses

Power and Control Intimidation ۰ Making threatening motions towards her ۰ Throwing things at or near her, her pregnant body or their baby ۰ Holding their baby during an argument

Power and Control Isolation ۰ Preventing her from getting prenatal care ۰ Preventing her from accessing information regarding her pregnancy ۰ Refusing or interfering with her contact with family and friends ۰ Limiting her choice of caregiver and support people for the pregnancy

Impacts of Violence ۰ Physical, physiologic, psychosocial ۰ Social ۰ Economic ۰ Acute, chronic, intergenerational Ripples § § § Social/behavioral Economic Epigenetic Life-course perspective ۰ Additive

Impacts Potential Consequences of Violence Physical • • Physical pain and harm to the mother’s bodily integrity Miscarriage Placental abruption Preterm birth Premature rupture of membranes Uterine rupture Hemorrhage Maternal and/or fetal death Psychological • • • • Depression Postpartum depression Anxiety Panic disorder PTSD High blood pressure High need for control Hyperarousal Substance use “Checking out, ” numbing, dissociation Isolation from peer support Low sense of self-worth and esteem Difficulty advocating for own desires with authority figures Difficulty breastfeeding Attachment difficulties Developmental • • Preterm labor Low birth weight IUGR Decreased blood flow to uterus Changes in mother’s hormones Increased infection Changes in baby’s genetic, nervous and hormonal systems and programming that can last their entire lifetime Gluckman, 2008; Neigh et al. , 2009; Rice & Records, 2008; Seng, 2002

Impacts - Neonate Physiologic measures pre and post PKU heel stick Suggest altered HPA axis in newborn 140 120 100 Abused mothers 80 Non-abused mothers 60 40 20 0 Maternal Newborn NB heart NB HR 5 min NBcortisol (NB) cortisol rate post 25 min post pre NB HR 25 min post (Rice & Records, 2008)

Youth - ACEs ۰ Adverse Childhood Experiences × “Adverse Childhood Experiences (ACEs) is the term given to describe all types of abuse, neglect, and other traumatic experiences that occur to individuals under the age of 18. The landmark Kaiser ACE Study examined the relationships between these experiences during childhood and reduced health and wellbeing later in life. ” CDC, 2013

Youth - ACEs ۰ Adverse Childhood Experiences (ACE’s) CDC, 2013

Youth - ACEs CDC, 2013

Youth - ACEs CDC, 2013

Impacts - Adolescence ۰ Lowered self-esteem ۰ Substance use ۰ Eating disorders ۰ Obesity ۰ Risky sexual behaviors ۰ Teen pregnancy ۰ Depression ۰ Trauma ۰ Anxiety ۰ Suicidality

Protective Factors ۰ Support system ۰ Past experiences coping and surviving ۰ Unique identification of strengths and resources ۰ Work experience – ability to get a job ۰ Access to resources, social capital ۰ Lack of a language barrier ۰ Community support and accountability

Interplay of Risk Factors and Adverse Events with those that Buffer, Protect, enhance Resiliency Shonkoff, 2010

Adulthood ۰ Women More likely to be abused in a relationship More likely to abuse children ۰ Men More likely to be abusive to partners and children

Intervening Connecting to caring and fostering resilience

Interventions ۰ Provider ۰ “Weaving a safety net” ۰ Organizational change ۰ Multidisciplinary commitment and collaboration ۰ Beyond healthcare: Social, cultural and economic

Interventions Doyle, 2009

Interventions ۰ ۰ ۰ ۰ Routine assessment , counseling and education § Referral as necessary Group prenatal care § Centering Pregnancy Nurse Family Partnership Social, emotional and parenting skills support Cognitive Behavioral Therapy Mentoring Turnaway Study - ANSIRH ۰ Findings suggest women receiving abortions more successful at escaping violent situation and partner than women denied and forced to carry to term. “…interrupt transmission, prevent future spread, change group norms in order to reverse epidemic …violence responds as a disease, validated in its outcome …” (Gary Slutkin, TEDMED)

Screening and Referral

Ask: Limits to Confidentiality ۰ Confidentiality § Professional interpreter services ۰ Trust § “I’m really glad you came in today. Before we get started I want you to know that everything you share with me is confidential, unless state laws/mandatory reporting requirements applicable to you, those things I would have to report, ok? ” (Futures Without Violence, 2012) Safety and health

Ask “Because these experiences are so common in women’s lives we ask all our patients …. ” ۰ Written and verbal screening Standard, routine questioning Instruments § New OB Visit packet § § § CDC: Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings Share with Women Safety cards Intake forms Verbal § § § Screening ۰ Safety cards ۰ History taking Probing ۰ Concerns ۰ Clarifying Non-disclosure

Ask “Because the following experiences are common in so many women’s lives, and because, even if they have been dealt with in the past, they can be triggered in pregnancy. Have you ever felt hurt in a physical or sexual way? Do you feel safe in your current relationship? ” § § Concerned: “What you are telling me about your relationship makes me wonder if there are other things that make you uncomfortable. Has there ever been a situation where he has hurt you or made you have sex when you didn’t want to? ” Non-disclosure: “I am really glad to hear nothing like this is going on for you. Should that ever change, this is a safe place to talk. ”

Acknowledge ۰ Disclosure Validate Empathize Supportive statements Anticipatory guidance

Assess ۰ Safety ۰ ۰ Need for evidence collection Perceived needs – “What can be done to support you? ” ۰ “Do you feel safe to go home today? ” ۰ “Are you afraid your partner may seriously harm you? Your children? ۰ “What is your plan to protect yourself and children from harm? ” § § ۰ ۰ § Health Children Economic Coping Support network Develop an immediate safety plan

Refer ۰ Domestic violence program Domestic Violence advocate ۰ Law enforcement and courts Legal advocate ۰ Social work ۰ Specialty care

Domestic Violence Advocate ۰ Domestic violence advocates Affiliation § Program vs. prosecutor ۰ Program/shelter ۰ YWCA State regulations Training involved

Assure ۰ You care about her health and safety ۰ Safe space ۰ Abuse is not her fault ۰ Follow-up plan (WA DOH, 2008)

Safe Homes, Safe Babies ۰ Perinatal Health Safety Card § How is it going? ۰ All moms deserve healthy relationships § On bad days? ۰ Is my relationship disrespectful § How is your health? How are you coping ? ۰ Coping strategies § Parenting is hard work ۰ Parenting after being hurt by someone you know and love can make the work even harder § § Who controls pregnancy decisions? Taking control back

Is your relationship affecting your health? ۰ General Health Safety Card § § Healthy vs. unhealthy relationship Encourages: ۰ social support ۰ stress reduction ۰ help seeking § § § Safety planning Health effects Impacts on children ۰ Positive emotional support ۰ Help seeking

Did you know your relationship affects your health? ۰ Reproductive Health Safety Card § § § Healthy vs. unhealthy Negative reproductive health impacts Reproductive options Reproductive control Safety planning

Triggers and Coping ۰ ۰ Trauma informed services Anticipatory guidance with check-ins Birth plan § § Trigger identification and coping Safe word Safety plan PTSD Dissociation Re-experiencing ۰ ۰ Social work and mental health consults Survivor Moms by Seng & Sperlich and When Survivors Give Birth by Simkin & Klauss

Documentation ۰ Health records being used in court cases Against women: § § § § No indication of abuse Unfit mother Credibility Substance use Inconsistencies Defend perpetrator’s character She has an agenda against abused Health records to be objective, reliable and sources of relevant facts Cory et al. , 2003

Documentation ۰ Routine counseling and screening for IPV and coercion ۰ Why screening was not done, plans to follow-up ۰ Response to screening ۰ Resources provided ۰ Referrals provided ۰ Follow-up appointment ۰ National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings × by The Family Violence Prevention Fund (Futures Without Violence)

Documenting Sexual Assault and Abuse ۰ Medical history ۰ Date & time Location Assailant name/info Mechanisms of injury Patient narrative Exam to include injury Photos/body maps Plan Interventions Collection of evidence Labs* § § § Medications § Physical assessment ۰ History ۰ LMP STI’s Wet mount Serum for HIV eval, hep B, syphilis § § Referrals § To include DV/SA advocate ۰ Shelter, YWCA, hotline, etc. Mandatory/patient sanctioned reporting Recommended follow-up § Emergency contraception Post-exposure prophylaxis GC/CT & Trich Repeat labs 1 -2 weeks Safety plan Answer questions Timeline/guideline for evidence processing Follow-up § § Repeat testing Specialty care

Coding ۰ Primary ICD-10 Codes E 967. 3 – Y 07. 03 – Male partner as perpetrator of maltreatment and neglect E 967. 3 – Y 07. 01 – Husband as perpetrator of maltreatment and neglect E 967. 3 – Y 07. 04 – Female partner as perpetrator of maltreatment and neglect E 967. 3 – Y 07. 02 – Wife as perpetrator of maltreatment and neglect 995. 81 – T 74. 31 XA – Adult emotional/psychological abuse 995. 81 – T 74. 11 XA – Adult physical abuse 995. 81 – T 74. 91 XA - Abuse of partner V 49. 89 – Z 91. 89 – At risk for intimate partner abuse V 23. 89 – O 9 A. 319 – Domestic violence affecting pregnancy 648. 93 – O 9 A. 311 – Domestic violence affecting pregnancy in first trimester 648. 93 –O 9 A. 312 – Domestic violence affecting pregnancy in second trimester 648. 93 – O 9 A. 313 – Domestic violence affecting pregnancy in third trimester V 11. 8 – Z 87. 898 – History of violence V 61. 11 – Z 69. 11 – Spouse/partner abuse victim counseling

Recommendations ۰ USPTF ۰ The USPSTF recommends that clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services. Grade B recommendation 2013 ACNM “Certified Nurse-Midwives (CNMs) and Certified Midwives (CMs), as advocates for and providers of primary women’s health care, have a critical role to play in mitigating the effects of violence in women’s lives. ” CNMs and CMs must understand the dynamics of violence against women and the impact of violence on the lives of women and their children. ” Appropriate assessment, intervention and referral for violence against women should be an integral part of all midwifery care. ” ACNM Position Statement on Violence Against Women

Recommendations ۰ ACOG Based on the prevalence and health burden of IPV among women, education during obstetric visits; and ongoing clinical care can improve the lives of women who experience IPV. Preventing the lifelong consequences associated with IPV can have a positive effect on the reproductive, perinatal, and overall health of all women. ۰ IOM Recommendation 5. 7: The committee recommends for consideration as a preventative service for women: screening and counseling for interpersonal and domestic violence. Screening and counseling involve elicitation of information from women and adolescents about current and past violence and abuse in a culturally sensitive and supportive manner to address current health concerns about safety and other current or future health problems.

Affordable Care Act ۰ ۰ ۰ IOM 2011 Report Clinical Preventative Services for Women: Closing the Gaps Routine screening and counseling 8/1/2012 Prohibit insurance company discrimination 1/1/2014 Reduction of teen pregnancies Tribal community support, prevention and treatment Home visitation and early childhood health § ۰ Safety card development Articulated as part of the National Prevention Strategy with ACA One of 7 national priorities “Injury and Violence Free Living” Futures Without Violence, 2012

Resources ۰ ۰ ۰ ۰ Future’s Without Violence HRSA CDC/ACOG ARHQ Washington State Department of Health SHE Framework March of Dimes § Abuse During Pregnancy

Futures Without Violence Formerly Family Violence Prevention Fund ۰ Addressing Intimate Partner Violence, Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic and Reproductive Health Care Settings ۰ National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings ۰ Safety Cards ۰ Webinars ۰ Fact Sheets

SHE Framework ۰ SHE Framework: Safety and Health Enhancement for Women Experiencing Abuse: A toolkit for health care providers and planners § by Jill Cory and Lynda Dechief from the BC Women’s Hospital and Health Center and BC Institute Against Family Violence 2007 Comprehensive resource Process for establishing solid Trauma Informed Care

HRSA ۰ A Comprehensive Approach for Community Based Programs to Address Intimate Partner Violence and Perinatal Depression January 2013 § § § Raising awareness Forming partnerships Developing cultural competency Addressing policy Implementing standards of care guidelines

Mandatory Reporting ۰ Domestic violence as reportable varies by state Use of weapons Exposure of children ۰ “Often women who have had experience with domestic violence have concerns about their child’s safety. Do you have any concerns for your child? ” No: resources available if this changes Yes: disclose mandatory reporter status § “I care about you and your child, and I need to ask you some questions about the safety of your child. Because of my professional responsibilities, I’m required to report any abuse or neglect of a child. Before we begin, do you have any questions about this? ” (WA DOH, 2008)

State by State ۰ Compendium of State Statutes and Policies on Domestic Violence and Health Care produced by the Family Violence Prevention Fund ۰ Fatality Review Teams ۰ Mandatory Reporting of Domestic Violence to Law Enforcement by Health Care Providers ۰ Insurance discrimination

Limitations in Research ۰ Research Quality Congruence and replication – little that has been done not “significant” ۰ Standardization Screening – universal, methodology Definitions ۰ Awareness Issue – IPV, impacts Prevention – you can have a role Interventions – can help! Interrupt, …, change norms ۰ Resources Time – clinician, training programs, practice Economic - reimbursement Emotional – secondary trauma, personal experiences and denial

Next Steps ۰ Increase awareness § you may have increased yours today, take this back to your colleagues, organization, and community ۰ comprehensive screening , counseling, education in your ۰ ۰ ۰ practice Commit as an individual and organization to the process of ensuring Trauma Informed Care Collaborate Research § § Sustainability of provider screening Amount of abuse

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