Despite the ACOG's recommendation that all women be screened for IPV, consistent with previous research (Burge et al., 2005
), two-thirds of the Latina women participating in this study had never been screened for IPV. There was discordance between characteristics of women who were screened for IPV and women who were IPV positive. In systems that depend on identifying cases based on risk factors this represents missed opportunities for screening and identification.
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.
The data analyzed for this paper are from one point during pregnancy collected following the first trimester. It is possible that the women in this study had not yet been screened by the baseline assessment but that they were subsequently screened during a future visit. Nevertheless, all women were interviewed after their first trimester suggesting few were screened early in their pregnancy despite visits during this period. This investigation focused on Latina women living in a metropolitan area within the US and cannot be generalized to other cultural groups or rural areas.
Our study suggests that systems and health care providers play an important role in helping to facilitate screening for IPV. This screening process is most effective with providers who have good communication with their patients. Good communication includes both listening and using understandable language and explanations. Ensuring that this bidirectional communication strategy is achieved, it is essential to achieve effective screening for IPV. Once conditions for screening are in place, appropriate management steps must be taken such as assessing safety and ensuring that safety plans and resources are provided to women who screen positive for IPV.
Another step supported by this study is that health care settings implement systemic approaches to screening in order to increase the likelihood of screening women. By implementing policies at the system level health care providers may become more aware of the importance of systematic IPV screening. Health care providers' offices, hospitals, and health systems could all implement systematic screening processes to increase the likelihood of women being screened for IPV, especially during pregnancy when women come into contact with the health care system frequently. Systematically screening pregnant women will help address an all too common problem affecting both the mother and the fetus in an already vulnerable population.