A recent report, Clinical Preventive Services for Women: Closing the Gaps
, that was published through the Institute of Medicine (IOM) recommends that IPV screening become part of routine preventive services for women.8
The IOM report is the latest in almost 20 years of similar clinical recommendations and guidelines targeted at improving IPV screening and response in health care settings. In 1992, the American Medical Association recommended screening all women for IPV,9
and other professional medical organizations widely endorsed these recommendations.10-13
However, the professional practice guidelines preceded both the evidence of effectiveness and the considerable implementation challenges. Studies that tried to assess the effectiveness of IPV screening quickly found that physicians were unable or unwilling to integrate IPV screening into their practice.14
Substantial barriers were identified that span the spectrum of physicians' knowledge, attitudes, beliefs, and behaviors.15-20
Even system-level interventions with extensive physician education demonstrated marked improvements in screening without an increase in IPV identification.21
During this time, the movement for the use of evidence to guide clinical practice was also developing. With the realization that many of our current treatment recommendations lacked high-quality evidence of effectiveness, the level of enthusiasm for IPV screening began to decrease. The inescapable fact is that, in spite of the well-acknowledged high prevalence of IPV exposure and knowledge of its adverse health consequences, these recommendations have been difficult to implement, and general discouragement has followed a chain of evidence-based reviews that have found no evidence that screening for IPV in health care settings reduces subsequent IPV or improves women's health.22-26
Concerns about taking limited physician time for screening that is not clearly associated with improved outcomes are understandable. However, recent evidence from several randomized clinical trials and new developments in the use of health information technology (HIT) have the potential to dramatically shift the balance in favor of routine IPV screening. Moreover, changes in the financing and restructuring of the way clinical care is provided and quality is measured are shifting the scope of health care system responsibility and opening up new opportunities for routine IPV screening in health care settings in ways that do not take physician time.
Before the 2009 study conducted by MacMillan et al,27
there were no large randomized controlled trials addressing the impact of IPV screening in health care settings. The MacMillan trial recruited 6743 women, aged 18 to 64 years, from 26 emergency departments and primary care sites. Participants were randomized into 2 groups: they either completed a validated IPV screen before seeing the physician or were placed into a “nonscreened” group. However, both groups were screened for IPV at the end of the visit and were given referrals to appropriate resources. The participants were then followed up for 18 months and were monitored for primary outcomes of exposure to future abuse and quality of life during that time. Secondary outcomes included depression, posttraumatic stress disorder, alcohol and drug abuse, global mental and physical health, and use of health and social services. One of the study goals was to specifically assess for any harms that were related to screening. During the initial clinic visit, 44% of currently abused women who were screened before seeing the physician and 8% of the control group (abused women who were screened at the end of their visit) discussed IPV with their physician. Women in both groups had reductions in IPV recurrence and improvements in quality-of-life scores. In addition, depression, posttraumatic stress disorder symptoms, and alcohol problems all improved; however, there were no statistically significant differences between the 2 groups. Unfortunately, loss to follow-up was more than 40% in both groups, and the women who were at higher risk and had greater abuse at baseline were more likely to be lost to follow-up. This loss to follow-up rate led the authors to speculate that it might be impossible to obtain adequate long-term follow-up with abused women. The significant investment made by the Canadian government to conduct this study resulted in the key finding that there was no evidence of harm related to screening.27
I would contend that the main finding of the MacMillan trial was that there is no support for physician intervention, since that was the only real difference between the groups. In contrast, the MacMillan study does offer observational support for the positive impact of systematic IPV screening and referral since all women in the trial were screened, and for ethical reasons, all abused women received referrals. In fact, there was no real “usual care” group, since actual usual care does not involve either IPV screening or referral. While this observational finding would not be enough to tip the balance of evidence in favor of routine IPV screening for the next United States Preventive Services Task Force review, there is new evidence cited by the IOM that may do this.
Specifically, the strongest evidence cited by the IOM comes from the recently completed National Institutes of Health-DC Initiative to Reduce Infant Mortality in Minority Populations, which compared perinatal counseling to usual care.28-30
The study enrolled 1044 pregnant African American women at 6 prenatal care sites in the District of Columbia and monitored them for 1 year. Screening for IPV and other psychosocial risks was done using a computer-based risk assessment. Abused women were randomly assigned to receive perinatal counseling before and after the birth of their baby. Social work intervention was delivered during routine prenatal and postpartum care by specifically trained social workers. Counseling for IPV emphasized danger assessment, safety behaviors, and information on community resources. Comorbid risks such as smoking and depression were also addressed. Results were very promising, and the high retention rate of 91% of enrolled abused women indicates confidence in the results. At follow-up, women in the intervention group had significantly fewer recurrent episodes of IPV during pregnancy and post partum (adjusted odds ratio, 0.48; 95% confidence interval, 0.29-0.80). Women in the intervention group also had better birth outcomes, including fewer preterm neonates (≤33 weeks) (1.5% vs 6.6%; P
=.03); lower rates of very low-birth-weight neonates (<1500 g) (0.8% vs 4.6%; P
=.52); and increased mean gestational age (38.2 weeks for the intervention group compared to 36.9 weeks for the control group; P
=.016). The trial also found that depression, smoking, and environmental smoke exposure decreased in the intervention group.28-30
The authors hypothesized that the integrated nature of the intervention that addressed depression along with IPV and other psychological/behavioral risks may have greatly contributed to the intervention's success.
With the new knowledge that routine screening in conjunction with ongoing social work counseling is effective in reducing prenatal IPV and comorbid adverse health behaviors and is associated with improved pregnancy and birth outcomes, the weight of the evidence is finally tipping toward routine IPV screening. The caveat is that this type of intervention has only been shown to be effective among young urban women engaged during the perinatal period in a close ongoing relationship with a medical facility that has high-quality IPV-trained social work resources. Therefore, more work needs to be done before we can make evidence-based recommendations for routine IPV screening of women in all health care settings.