During fall of 2007 until 2008, Valerie Luckenbihl was repeatedly beaten by her boyfriend Timothey Kindle. Luckenbihl, age 17 at the time, was pregnant with Kindle's child. Although Luckenbihl obtained a protection order, the violence didn't stop until the death of the baby at around 22 - 24 weeks. The newspaper report stated that Kindle allegedly admitted to police that he was punching Luckenbihl in the abdomen, "with the intent of terminating the pregnancy" (McRann, 2012).
Aaron Fitzpatrick was sentenced to life in prison for the murder of his pregnant girlfriend, Tiffany Gillespie and her unborn child (Associated Press, 2015). A news report quoted Homicide Captain James Clark as stating after the arrest: "They had been arguing over the last 24-hour period. He was upset with the fact that she was pregnant with his baby and he killed her for that"(Gregg 2012), although post-mortem DNA analysis revealed that Fitzpatrick was not the father (Slobodzian, 2015).
These examples are not isolated incidents. According to the American College of Obstetricians and Gynecologists (ACOG) "approximately 324,000 pregnant women are abused each year in the United States" and "the severity of violence may sometimes escalate during pregnancy or the postpartum period" (ACOG, 2012).
Horon and Cheng (2001) showed that homicide was the leading cause of death during pregnancy in Maryland during the period 1993-1998. Since then, additional studies have shown that homicide is a leading cause of death in pregnant and postpartum women throughout the entire United States. (Chang, Berg, Saltzman, & Herndon, 2005). Horon and Cheng (2005) also demonstrated that these deaths are underreported due to inadequacies in the surveillance system (Horon and Cheng, 2005). The majority of deaths are "perpetrated by a current or former intimate partner" (ACOG, 2012). The risk of death is highest during the first three months of pregnancy (Cheng & Horon, 2010), the time during which most pregnancies are discovered and in which most pregnancy decisions are made.
However, research shows that abortion is not a solution to the problem of IPV during pregnancy. A meta-analysis of 74 studies from around the world revealed that IPV is associated with abortion, and even more highly associated with repeat abortion (Hall et al., 2014). Women presenting for a third abortion were more than 2.5 times more likely to have a history of IPV compared to women presenting for their first abortion (Fisher et al., 2005). Male perpetrators of IPV were more likely to have been involved in three or more pregnancies ending in abortion (Silverman et al., 2010). Thus, "violence can lead to pregnancy and to subsequent termination of pregnancy, and … there may be a repetitive cycle of abuse and pregnancy" (Hall et al., 2014).
Because of the links between reproductive health and IPV, ACOG recommends IPV screening annually during routine healthcare, at least once per trimester during pregnancy, and again during the post-partum period (ACOG, 2013).
It's important to screen all patients, and to let women know they are not being "singled out" (Judy Chang et al., 2005). As long as women know that you're talking to everyone about IPV, women are comfortable being screened, and actually "welcome" screening (Hall et al., 2014; Sohal et al., 2007). ACOG recommends that a "framing statement" should be provided at the beginning of the screening "to show that screening is done universally and not because IPV is suspected" (ACOG, 2012). Let women know that IPV is such a frequent issue that your center's policy is to ask everyone, just in case this could be occurring.
In addition, it's essential to screen women for IPV individually in a private area, not in the waiting room, where others may see her responses on a questionnaire or hear her replies to questions. Research shows that women decline screenings in the waiting room, but appreciate being screened privately (Sohal et al. 2007).
If a male partner, or anyone else, accompanies the patient to the center, it's essential to make them wait in another area until you've had time to complete the screening privately, and to verify whether the woman desires to have the other person with her during the office visit. Even if the partner resists, explain that due to privacy laws - or center policy - you are required to see her alone first.
It's also important to understand that you have to ask questions. "The majority of women who are experiencing IPV do not spontaneously disclose to clinicians" (Sohal et al., 2007). Direct questions in plain English are necessary, and that is what you will find in evidence based screening tools such as the Abuse Assessment Screen (AAS) (Basile et al., 2007) or the HARK (Sohal et al., 2007).
The AAS has been recommended in a publication of the Centers for Disease Control and Prevention (CDC), and is the only screening test recommended by the CDC that has been studied in pregnant women (Basile et al., 2007; McFarlane et al., 1992). The AAS, available in Spanish and English, is currently available online free of charge (Basile et al., 2007). It is recommended that clinicians read the questions to the woman privately (without the partner present) which is how the screening was done in the study showed the effectiveness of this screening tool (McFarlane, 1992).
The five questions of the AAS that are asked by the clinician are:
The HARK is another evidence based screening tool that is based on the questions of the AAS. Research shows that it is an effective screening test, but it does not ask any questions specifically related to abuse during pregnancy (Sohal et al., 2007).
Experts have found that it's best to ask about specific actions like slapping or kicking, rather than simply asking about "abuse;" women know if they have been slapped or kicked but don't necessarily think of that as abuse. Likewise, it's important to ask about "forced sex," rather than rape, as women may have been forced, but may not consider it rape if it was a partner rather than a stranger, and if no weapon was used (Campbell, 2016).
If your assessment reveals IPV is occurring, respond with empathy, and validate her feelings. Let her know help is available - but don't pressure her to leave her partner immediately. Women are actually in greater danger at the time of leaving a violent relationship, so careful planning is essential. The woman also has to be ready to leave; often there is a process of gradually becoming ready to make changes (Judy Chang, et al., 2005). Be aware of the range of resources that may be helpful, and offer women choices, remembering to respect her needs for safety, privacy, and autonomy (Judy Chang et al., 2005). It's also recommended that you offer some information about IPV to all who were screened; some women may not disclose IPV, but may still be helped by having the opportunity to receive and consider information about resources.
"This article was first published in Medical Matters, a newsletter of Heartbeat, International, in March, 2017, and used with permission.