Maternity Care Calendar and Guidelines: Screening for Domestic Violence

Domestic violence is chronically under identified. In the Canadian Violence Against Women Survey, 1993, 29% of women reported a history of assault by a spouse at some time. [2] Data from the 1999 General Social Survey, conducted by statistics Canada, show that an estimated 3% of women experienced some type of violence committed by their partner within the previous 12 months.[3] These rates are similar to those reported in other national surveys in the US (25% ever assaulted, 1.5% assaulted in the last 12 months), Australia (23% ever assaulted, 2.6% assaulted in the last 12 months) and the UK (23% ever assaulted, 4.2 % in the last 12 months). Some developing nations report even higher rates: Nicaragua (52% ever assaulted), Mexico (33% ever assaulted), Korea (37% assaulted in the past year) and Malaysia (39% assaulted in the past year). [2] Some American data show that 31% of women report being abused at some point in their lifetime, and between 1 and 4 million women are abused by their partners each year.[4] In another Canadian study, 5.7% of women interviewed reported experiencing physical abuse during pregnancy and 8.5% reported experiencing it within the preceding 12 months.[5]

Domestic violence may begin during pregnancy or the postpartum period and ongoing violence may become more severe during pregnancy. [1, 6-10] Some authors have reported an association between domestic violence during pregnancy and adverse effects on the health of the baby, such as an increased rate of miscarriage, prematurity, antepartum hemorrhage, low birth weight and fetal death.[1, 6, 7, 11-18] An association between domestic abuse and low birth rate has been reported.[19-21] As well, several authors have described increased self-reported rates of miscarriage, attributed by the women surveyed, to domestic abuse. [6, 7] Domestic violence can indirectly lead to adverse pregnancy outcomes by affecting women's health behaviors [22]. For example, domestic violence has been associated with delayed entry into prenatal care, increased tobacco, alcohol and illicit drug use and poor nutrition.[23] One systematic review of the literature found that no adverse pregnancy outcome was consistently associated with violence during pregnancy.[24] However, the authors acknowledge that methodologic limitations and lack of comparability of the findings make it impossible to draw definitive findings.

Prenatal visits provide the physician with an occasion to screen those women for domestic violence who may not otherwise see a physician regularly.[1, 25-27] In addition, pregnancy affords a key opportunity for intervention in domestic violence situations as women are more likely to utilize resources for the sake of their baby.[26, 28]

Barriers to screening
Although most agencies recommend 100% screening of women for domestic violence, studies have shown that the actual rate of screening in primary care facilities is far below this.[25, 27, 29-31] Some of the barriers to screening include: lack of clinical guidelines regarding how and when to screen, the lack of time during most office visits, physicians' discomfort with the topic of domestic violence, fear of offending patients, a lack of effective interventions to aid the victim, and a misconception about the nature of the typical victim. [1, 27, 32]

Screening
The US Preventive Services Task Force (USPSTF) and the Canadian Task Force on Preventive Health Care (CTFPHC) have two criteria for an effective screening test:" [33, 34]

• the test must be able to detect the target condition earlier than without screening and with sufficient accuracy to avoid large numbers of false-positives and false-negatives
• screening for and treating persons with early disease should improve the likelihood of favourable health outcomes (e.g. disease-specific morbidity or mortality) compared to treating patients when they present with signs or symptoms of the disease.

Studies have shown that the integration of a domestic violence screening protocol into routine history taking procedures increases the rate of identification, documentation, and referral of intimate partner violence .[25, 35-37] However, the ability to generalize the results of these studies to the general population is limited by the specific ethnic or regional nature of the patient sample used in the studies. [25, 31] In addition, numerous studies have indicated that women find screening for domestic violence acceptable, although it must be acknowledged that a significant minority of women also objected to routine screening for domestic violence. [6, 31, 38, 39] Furthermore, "researchers who have studied battered women and rape victims emphatically state the single most important service that professionals can perform for victims of violence is to ask about the abuse," as spontaneous disclosure is rare. [40, 41]

Although many studies conclude that screening is the right thing to do, they also suggest that most screening tests need formal scientific evaluation to define such concepts as a false negative test in a domestic violence screen.[42] In addition, at this time there is insufficient evidence to suggest that health outcomes for the patient will be improved by early detection of domestic violence [6, 30, 31, 37, 42-44] Three recent systematic reviews all concluded that there is insufficient evidence that screening for domestic violence improves health outcomes. [37, 45, 46] As such, the domestic violence screen does not meet the criteria set out by the USPSTF and CTFPHC. However, many authors have advocated that domestic violence screening is justified on other grounds including its high prevalence in the population, high level of patient acceptance of screening, minimal costs, the low risk of harm of screening and significant potential benefits.[1, 23, 30, 42, 47, 48] Although more research is needed to scientifically evaluate screening for intimate partner abuse, physicians should not wait for such research before they begin to screen in their own practices.[42, 43]

Screening Tests
When asked, physicians noted that one of the major barriers to screening for domestic violence was difficulty with what to ask.[32] Furthermore, studies have shown that the rate of screening and documentation of intimate partner violence was much higher at primary care settings with a standardized domestic violence screen than at those settings where physicians were simply asked to screen for domestic violence without being provided with a screening test.[25, 36]

McFarlane et al. compared the accuracy of the 3-question Abuse Assessment Screen in pregnant women, against 2 detailed violence measures, the Index of Spouse Abuse (ISA) and the Conflict Tactics Scale (CTS) -often considered the established "gold standards". [11] The 3 questions of the AAS were:

1. Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? If yes, by whom?
2. Since you've become pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone? If yes, by whom?
3. Within the last year, has anyone forced you to have sexual activities? If yes, by whom?

They found that the AAS detected a prevalence of 17% of physical or sexual abuse and when compared to the ISA and the CTS the AAS was valid and reliable. The sensitivity, specificity and predictive value were not reported.

Another American study found that the use of the AAS in a prenatal clinic improved the detection of domestic violence compared to standard history (41% vs. 14%) [49]. In a Canadian study, using the AAS, the rate of reported physical abuse in pregnancy was 5.7%. [5]

Feldhaus et al. compared the accuracy of the 3-question Partner Violence Screen (PVS) in the emergency room setting, against the same 2 detailed violence measures, the Index of Spouse Abuse (ISA) and the Conflict Tactics Scale (CTS). [50] The 3 questions in the PVS were:

1. Have you been hit, kicked, punched or otherwise hurt by someone within the past year?
2. Do you feel safe in your current relationship?
3. Is there a partner from a previous relationship who is making you feel unsafe now?

They found that the 3 brief questions, that took an average of 20 seconds to administer, will detect 64.5% to 71.4% of women who screened positive on the IAS and CTS respectively. The specificity of the test was 80.3% to 84.5%. In fact, the first question alone detected almost as many of the abused patients as the overall PVS, with better sensitivity.

A third tool, the 7-question Woman Abuse Screening Tool (WAST), was tested using 24 abused women staying at a women's shelter and 24 controls, known not to be abused.[51] It was found to be highly reliable. The WAST has been incorporated into the Antenatal Psychosocial Health Assessment (ALPHA) form, an evidence-based screening checklist for psychosocial inquiry.[52] The 2 questions the abused women reported being most comfortable with were used for the WAST-short. The WAST- short correctly classified 100% of the non-abused women and 91.7% of abused women. The two questions were:

1. In general how would you describe your relationship?
   • a lot of tension
   • some tension
   • no tension
2. Do you and your partner work out arguments with….
   • great difficulty
   • some difficulty
   • no difficulty?

Neither the WAST nor the PVS was specifically tested in pregnant women. The PVS has also not been tested in the primary care setting. The WAST was shown to be reliable in the primary care setting. [53]

Although screening tools vary in terms of the wording of the question, they are all designed to be used on a routine basis in every woman and they have all been found to be reliable in their ability to increase the detection of abuse.[54]

Women should never be asked about abuse in the presence of their partners or other family members.

Introductory statements that normalize the questions such as: "many women have experienced some form of abuse in their childhood or adult life. Past or current abuse can affect a women's health in many ways that concern us, so we ask all women about this possibility" are recommended. [54]

The Society of Obstetricians and Gynecologists of Canada recommends universal screening of pregnant women for domestic abuse.[7, 56]

A recent review by the US Preventive Service Task Force [4, 46, 57] concluded:
"There is insufficient evidence to recommend for or against routine screening of women for intimate partner violence"

The US Task Force report released in 1996 noted that including a few direct questions about abuse (physical violence or forced sexual activity) as part of the routine history in adult patients may be recommended on other grounds ("C" recommendation). These other grounds include the substantial prevalence of undetected abuse among adult female patients, the potential value of this information in the care of the patient, and the low cost and low risk of harm from such screening. [34]

The Canadian Task Force on Preventive Health Care just completed a systematic review on interventions for violence against women which is available on their website. [45, 58] (www.ctfphc.org) The report focuses primarily on the effectiveness of treatment interventions. The authors explain that although a number of screening tools with reasonable accuracy exist, there are no studies of effectiveness of these screening tools, using improved outcomes for women as the endpoint. The CTFPHE concludes:

• There is insufficient evidence to recommend for or against screening for violence in pregnant women. (I recommendation)
• Note: "This is distinct from the need for clinicians to include questions about exposure to domestic violence as part of their diagnostic assessment of women." Physicians should remain alert for signs and symptoms of IPV and question women when abuse is suspected. Also information about IPV may inform the assessment and management of other health issues.

National Institute for Clinical Excellence (NICE) [59] Antenatal Care: Routine care for the healthy pregnant woman guidelines state "Healthcare professionals need to be alert to the symptoms or signs of domestic violence and women should be given the opportunity to disclose domestic violence in an environment in which they feel secure" (Grade D rating)

The Institute for Clinical systems Improvement (ICSI) state that "domestic violence is a serious public health problem for many Americans. In accordance with the ICSI Preventive Services, Preventive counseling and Education, and Preterm Birth Prevention guidelines, screening for domestic violence should be done at a preconception visit and the first and fifth prenatal visit. [60] http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=170

The recommendation "screen for domestic violence" cannot be bolded due to the lack of evidence to date showing that screening improves health outcomes. However, in an effort to facilitate screening by maternity caregivers, screening questions will be added to the maternity care guidelines.

The new guideline on the MCC will be as follows:

• Screen for domestic violence:
• "Do you ever feel unsafe at home?"
• "Have you been hit, kicked, punched or otherwise hurt by someone within the past year?"


• it will be in plain font
• it will be listed under "Clinical" interventions suggested for the first antenatal (although screening is also appropriate at the preconception visit, in each trimester and postpartum)

Thank you to Dr. Patti Janssen, Assistant Professor, Dept of Health Care and Epidemiology, UBC and Associate Faculty, Dept of Family Practice and BC Research Institute for Children's and Women's Health, And Nadine Wathen from the Canadian Task Force on Preventive Health Care for their review and helpful comments.