Pregnant women who experience IPV are at increased risk for several adverse health conditions. Depression and post-traumatic stress disorder (PTSD) are common conditions associated with IPV (Bonomi et al., 2006; Flynn et al., 2007; Lipsky et al., 2005). IPV among pregnant women is of great concern due to the deleterious impact on the pregnancy such as antepartum hemorrhage, intrauterine growth retardation, perinatal death, abortion/miscarriage, low birth weight, preterm labor, as well as risk for homicide (Jansenn et al., 2006; Glander et al., 1998; Hedin & Janson, 2000; Murphy et al., 2001; McFarlane et al., 2002; Anderson et al., 2002). Moreover, pregnant women exposed to IPV are more likely to obtain prenatal care later in their pregnancy, making it more difficult to address potential complications (Anderson et al., 2002; McFarlane et al., 1992).

The American College of Obstetrics and Gynecology (ACOG) recommends screening all women for IPV due to its high prevalence and associated adverse health consequences (ACOG, 2006.) In August of 2006, the Committee on Health Care for Underserved Women developed a statement endorsing screening of IPV as part of the comprehensive care that women receive when seeking pregnancy evaluation or prenatal care (ACOG, 2006). Even still, few clinicians routinely screen for IPV leading to low rates of detection (Kaur & Herber, 2005; McCaw et al., 2001; Glass et al., 2001) despite the availability of brief and valid IPV screening tools for Latinas and other women (Wrangle, 2008; Soeken, 1998). Moreover, not all professional organizations agree that screening should be conducted universally (U.S. Preventative Services Task Force, 1996).

Factors associated with screening are generally associated with a perceived risk for abuse (Witting et al., 2006). Without universal screening procedures in place, screening generally occurs for those who are suspected of being involved in abusive relationships (Horan et al., 1998). Health care providers also may not screen patients due to feeling uncomfortable discussing IPV with patients and feeling they do not have sufficient time or experience to address IPV issues (Taft et al., 2004; Waalen et al., 2000; Rodriguez, et al., 1998; Rodriguez et al., 2001). While the majority of women support the need for screening, they also face barriers in disclosing IPV to health care professionals (Bauer et al., 2000; Chang et al., 2003; Gerbert et al., 1999; Hamberger et al., 1998; Plichta, et al., 1996). Barriers may vary if the women are immigrants or Latinas (Sokoloff et al., 2005; Raj & Silverman, 2002), suggesting a need to better understand these subgroups to tailor programs appropriately. An earlier study of Asian and Latina immigrant women found that social isolation, language, family dedication, discrimination, shame, stigma and fear of deportation were some barriers to patient-provider communication and help seeking (Bauer et al., 2000).

As expected, having a systematic approach in place to ask about IPV during pregnancy was the variable that was most associated with being screened for IPV. Having institutionalized systems in place significantly increases the likelihood that all patients are screened for IPV. This is consistent with other studies that focus on promising multi-faceted interventions that involve screening, staff training, telephone based counseling by a case manager (Krasnoff & Moscati, 2002) and providing contact information for self-referral to on-site services that may improve access to IPV care (Kaur & Herber, 2005; McCaw et al., 2001, Crandall et al., 2005; Hobson et al., 2005; Maiuro et al., 2000). This supports the need for systematic approaches to screening and responding to patients with a history of abuse.

Communication between the women and health care providers was also very important. If women perceived that health care providers listened to them and always gave understandable explanations, women were more likely to be screened for IPV. This reinforces the importance of creating an atmosphere of support, safety, respect and trust. Clinician behaviors that foster this trust and subsequent disclosure of IPV included good communication by clinicians (Battaglia et al., 2002). Patients report that being listened to and not being interrupted by the provider as extremely important in the patient-provider interaction (Hobson et al., 2005). While the literature details the importance of good patient-provider communication, few examine the relationship between this important facet of the relationship and the influence it has on screening for IPV(Maiuro et al., 2000). Other studies show that providers who had higher self-rated confidence in their ability to ask patients about IPV had a greater likelihood of screening for IPV (Jonassen & Mazor, 2003). Increased IPV training for health care professionals in this area could potentially increase the likelihood of more women being screened and help health care providers feel more confident performing this task. Some studies suggest that communication barriers may be related to the practice setting and gender of the health care provider (Jonassen & Mazor, 2003). Uniform, standardized procedures in place should help address variability in settings. A 2006 meta analysis showed that female patients desired certain communication patterns from their health care providers when responding to their abuse disclosure including nonjudgmental, nondirective, and tailored responses that demonstrated an understanding of the complex nature of IPV (Borowsky & Ireland, 2002). While this study only examined responses after disclosure, it shows that the nature of the relationship and the communication patterns between patients and health care providers is important.

Women who reported that they were using contraception during the period of conception were more likely to have experienced IPV. These findings are consistent with several other studies (Palitto et al., 2005; Palitto & O'Campo, 2004; Lau, 2005; Gazmararian et al., 2000; Saltzman et al., 2003; Goodwin et al., 2000). In those studies, if there was an unintended or unwanted pregnancy, women were four times more likely to experience violence. In an earlier study conducted in the US to explore the relationship between violence, sexual coercion, and pregnancy, some women felt they could not avoid intercourse with their abusers, despite fears of pregnancy (Goodwin et al., 2000).

Significant health and social consequences are related to IPV and include acute and long-term psychological, physical, social and economic effects, with the costs of IPV exceeding $5.8 billion each year including $4.1 billion in direct medical and mental health care services (Drauker, 2002; Max et al., 1999). Screening and intervention for IPV that occurs early and systematically may minimize the health and economic impact on women, providers and health care systems. Evidence of good communication between providers includes both listening to the patient and giving explanations that are understood by the patient. Providers who recognize specific factors associated with IPV may better identify IPV. Missed opportunities for IPV identification allow IPV to remain under-diagnosed, and under-managed and may further impact the health of vulnerable women. These findings emphasize the potential importance of system level policies in influencing provider behavior. It also highlights the possible importance of excellent communication in influencing screening practices.