Intimate partner violence (IPV) during pregnancy affects many women worldwide. Global prevalence figures show that one in three women will experience IPV at some point in their lives [1]. Between 1.5 and 5.3 million women are physically and/or sexually assaulted per year by an intimate partner [2]. Intimate partner violence is a huge public health issue, costing the U.S. an estimated $8.3 billion dollars annually. Pregnancy is a particularly vulnerable time for many women, as violence is more likely to begin or intensify [3]. Screening for IPV is a standard of care recommended by the United States Preventive Services Task Force [4] and other organizations; however, the literature demonstrates a deficiency in health care provider preparedness, comfort, and consistency [2]. Screening women during prenatal appointments is an ideal time for practitioners to identify IPV. Because of the prevalence of IPV, and because it may take time to build enough trust with an abused woman to disclose her situation, it is recommended to universally screen all pregnant women for IPV at least once each trimester.

Problem Statement

In the United States, it is estimated that over half a million sexual or physical assaults against women are perpetrated by intimate partners each year. Additionally, IPV is more common during pregnancy. Intimate partner violence is more prevalent than preeclampsia and gestational diabetes during pregnancy, yet providers are not required to universally screen patients for IPV. Intimate partner violence is especially dangerous during pregnancy as it predisposes women to complications related to stress such as delayed start of prenatal care, lack of compliance with prenatal care, higher rates of substance abuse and smoking. Direct complications of IPV from violence include, preterm labor, fetal injury or death. IPV is known to have serious, broad and long-lasting impacts on the physical and mental health of women and their children, yet there is no standardized screen for IPV during pregnancy. It would be of great interest to explore the impacts of screening pregnant women for IPV.

Purpose of Study

The purpose of this integrative literature review is to explore the effectiveness of screening pregnant women for IPV by practitioners during prenatal appointments. Practitioners are in an ideal position to screen and support pregnant women experiencing IPV due to the nature of the relationship and the many times that women visit the practitioner during pregnancy. This review will categorize and synthesize twelve national and international peer reviewed articles that screen pregnant women for IPV to help demonstrate the effectiveness of screening to decrease the incidence. This review will aid in bringing awareness and education to practitioners about the importance to screen women for IPV during pregnancy. This review is one of the first steps to decreasing the occurrence of IPV during pregnancy as it will empower practitioners to get familiar with interventions and support services for the women that screen positive.

Research Question

Intimate partner violence is prevalent among women, especially when pregnant. During the time of pregnancy women are routinely seen for obstetric visits by their practitioners who make this an ideal time to screen. Which leads to the question, would the incidence of IPV decrease if women were routinely screened throughout pregnancy by their practitioners?

Methodology

This literature review was conducted to address the PICOT research question; would IPV decrease during pregnancy if patients were routinely screened by practitioners? The topic was researched by using electronic databases, Cochrane Library, MEDLINE, CINAHL (Cumulative Index of Nursing and Allied Health Literature), and the U.S. National Library of Medicine/PubMed. These electronic databases were made available through the online library at MCPHS University. The search was limited to articles published between January 2008 and November 2016. The articles chosen were peer-reviewed only and include quantitative and qualitative, national and international and all published in English. Twelve peer-reviewed articles were chosen that met the inclusion criteria.

Critique of Literature

About twelve articles were included in this integrative literature review. Of these twelve, seven concluded that IPV screening during pregnancy is beneficial in identifying the problem, which could help aid in decreasing the occurrence through awareness and treatment [5]. The findings of the remaining five articles supported the theory that through education, practitioners can learn to implement interventions to their patients that screen positive and decrease the occurrence of IPV.

In the first article [6] 431 pregnant women are screened for IPV by 204 nurses during home visits. The screening tools used included the Conflict Tactile Scale (CTS) and Child Abuse Potential (CAP) scale. The findings using the CAP scale were inconclusive as 98% of nurses used the CTS scale as it was more relevant to IPV. The results of the CTS scale proved that of the 52% (n=224) of women that screened positive for IPV initially, decreased to 43% (n=185) after they sought out support from family, friends and healthcare professionals. The study concluded that pregnant women are a vulnerable population for IPV and support is essential for these women, specifically by friends, family, and/or support groups. Findings suggest that there is a noticeable difference in the incidence of IPV after interventions such as support is offered to the women who screen positive.

Baird et al. offered information from a 5 year follow up to a previous study on IPV during pregnancy [7,8]. The study included a sample of 58 midwives, 73% (n=36) who were part of the original study in 2004/2005. A program was put in place for the midwives that offered extensive training on IPV. All 58 midwives unanimously agreed that training was beneficial to them as providers and better equipment them to assess for IPV in pregnant women. The 5 year follow up surveys concluded that the IPV program was beneficial in reducing IPV during pregnancy.

Chambliss [3] solely comprised the research of certified nurse midwives (CNM). The sample size was small, only including 8 CNM’s. Also, the CNM’s worked in different settings, 4 working at obstetric offices and 4 working at birthing centers. Of these 8 CNM’s, only 2 had 5+ years of experience as a CNM. There was no screening tool used in this study, each CNM individually interviewed each patient for IPV during obstetric appointments. Although the sample size was small, all 8 CNM’s agreed that there was an absolute need for a universal screening tool to assess for IPV.

Jahanfar et al. measured the efficiency of IPV interventions for women that screened positive during pregnancy [8]. The CTS scale was used on 3417 pregnant women by their obstetric providers. The pregnant women who screened positive warranted for IPV intervention, which included a brief counseling session by a trained healthcare provider [5]. Of the women who received the IPV intervention, they were contacted one year later to calculate the effectiveness of the intervention in decreasing IPV. The IPV intervention proved to be effective as the women contacted reported a decrease in psychological abuse by 17% and a decrease in physical violence by 10%.

Lo-Guidice [9] was a qualitative study. This study interviewed 142 women’s healthcare practitioners on their professional experiences with screening women for IPV during pregnancy. The study pointed out many of the barriers that hindered practitioners from routinely screening their patients for IPV. These barriers included: time constraints, limited knowledge about IPV, and feeling inadequate to help if a patient screens positive [9]. The study suggests that practitioners would benefit from IPV education. Education on IPV would empower practitioners and give them the confidence they need to screen, treat and refer patients that screen positive to the appropriate services.

Modiba et al. [10] conducted a quantitative cross sectional study on the prevalence of IPV among pregnant women and the need for an abuse screening program in Gauteng Providence in South Africa [5]. The study screened 163 pregnant women, of these women 41% (n=66) screened positive for IPV. More specifically, 26% (n=42) reported being emotionally abused by their spouse, 17% (n=27) reported being physically abused, 9% (n=14) reported being sexually abused and 5% (n=8) reported being abused both emotionally and physically. The prevalence for IPV was significantly higher in this study when compared to the others, this was also the only study conducted internationally. This study proposes that IPV is a global issue and that universal screening could benefit all women.

Nelson et al. [11] screened 6734 women, pregnant and nonpregnant during medical office visits. The two screening tools used were the Humiliation, Afraid, Rape, Kick instrument (HARK) and the Women Abuse Screening Tool (WAST). The study reported that the group of women who were screened with one of the two tools, 44% (n=2962) screened positive. In comparison to the group of women who were not screened with one of the tools and instead was casually asked about IPV, only 8% (n=538) screened positive for IPV. The study concluded that IPV is prevalent among women of all ages and women are being underdiagnosed for IPV as there is no recommended screening tool in place. The findings suggest there is a need to implement a universal IPV screening tool for women.

O’Doherty et al. [12] screened 2765 women, pregnant and nonpregnant during healthcare visits for IPV. The screening tool used was the Abuse Assessment Screen (AAS). Of the women screened with the tool 88% (n=2433) were found to be at risk for IPV. The study did not differentiate between women experiencing IPV and those at risk. Women who were not screened using the tool and were given routine care reported being at risk for IPV as well, but only 43% (n=1188) reported being at risk. The findings of this study indicate that all women should be screened for IPV, especially high risk groups, such as pregnant women [5].

O’Reilly et al. [13] was a randomized study that screened 384 pregnant women during obstetric appointments for IPV. The screen used was the popular AAS tool. Evidenced based practice suggested that prenatal visits would be ideal to screen for IPV, as the spouse is not always there and patients develop trusting relationships throughout their pregnancy with their healthcare providers [5]. The study also indicated that women should be screened at multiple times in their pregnancy, as they may not feel comfortable disclosing this information at first and/or they may be accompanied by their spouse [5].

Sawyer et al. [1] conducted a systematic search of multiple databases of studies that included IPV educational interventions, of which 18 were selected for inclusion [5]. The healthcare providers in this study did not include practitioners; instead it included nurses, social workers and paramedics. Findings concluded that providing healthcare providers with education on IPV improved knowledge, attitudes, skills and behaviors. This review made it clear that there is a need for highquality studies to examine the current evidence for IPV education so that it may inform practitioners of educational interventions for IPV [5].

Sharps et al. [6] screened 431 pregnant women during home visits by 204 nurses for IPV. The tools used were the popular CTS and CAP scale. The study only used statistics from the CTS screening tool as the CAP scale was less focused on IPV. Of the women screened with the CTS scale, 52% (n=224) of women screened positive for IPV. These women were offered treatment in the form of support groups and were rescreened with the CTS tool in which only 43% (n=145) screened positive for IPV. The study suggested that women, especially when pregnant are vulnerable to IPV. The study most importantly highlighted the need to screen for IPV and provide support. Best practice screening protocols should be implemented to women during pregnancy and support should be offered to the women who screen positive [5].

Thomas et al. [2] conducted a systematic random review of 692 women, pregnant and non-pregnant, ages 16 to 55. The screening tool used was the Partner Violence Screening Tool (PVST). Of these 692 women 35% (n=242) screened positive for IPV. The study indicated that the PVST was adequate in detecting IPV but healthcare providers lacked the education, preparedness, and comfort to deal with the women who screened positive. Healthcare providers voiced being more apt to change and maintain IPV screening recommendations after educational training sessions were conducted.

Velasco et al. [14] screened 750 pregnant women in hospital settings by 15 CNM’s for IPV. The screening tools used were the Index of Spouse Abuse (ISA) tool and the AAS tool. The purpose of the study was to compare the results of each tool when screening the same patients. The AAS tool revealed that 7.7% (n=57) women screened positive for IPV in comparison to 21% (n=157) that screened positive using the ISA tool. All 15 CNM’s unanimously agreed that different IPV screens yield different results and more research is needed to identify an IPV screen that can be universally applied [5].

Synthesis of Literature

Each of the twelve studies had multiple strengths. For example, Chambliss [3] made the point that healthcare providers, particularly those who care for pregnant women, are in a unique position to identify with these women and direct them and their families to end IPV. All twelve studies agreed that healthcare providers are in an ideal role to screen women for IPV as there is a unique patient and provider relationships, especially during pregnancy. O’Reilly et al. [13] made the argument that women should be screened for IPV at multiple times in their pregnancies, as initially they may not feel comfortable disclosing this information and/or they may be accompanied by their spouse. It is difficult to open up to someone you just met, therefore rapport must be made. Obstetric appointments are ideal as there are so many and it is unlikely that women come accompanied by their spouse every time.

A limitation to this review is that only four out of the twelve reviews used the same IPV screening tool, while the other eight used different screening measures. The lack of consistency in screening tools made the research difficult to compare. There was consensus by all twelve articles for the need of a universal screening tool to be used by healthcare providers. There is much research needed to assess which screening tool would be most effective.

Thomas et al. [2] identified the need for practitioners to be receiving IPV education in order to confidently screen, identify and address IPV with their patients. This was an area of concern with most of the articles as IPV was being screened for but practitioners did not know what to do with this information. The first step is identification but not unless there are effective interventions can the incidence of IPV be decreased.

Sawyer et al. [1] identified the positive correlation between practitioners instituting IPV interventions to patients that screen positive and a decrease in the occurrence of IPV. This study directly answered the PICO question in this literature review. By screening pregnant patients for IPV and providing IPV interventions, such as support groups, decreases the incidence of IPV. It is unclear if screening alone decreases the incidence of IPV.

All twelve studies agreed that there is a need for further research on IPV screening and interventions during pregnancy. For example, Sawyer et al. [1] pointed out the need for more high-quality studies in the future to better evaluate the effectiveness of specific IPV interventions. All twelve studies agreed that a constraint of the research was the limited amount of studies found on IPV screening that primarily focused on pregnant women. Another limitation of this review is that only five out of the twelve articles included advanced healthcare practitioners, which supports the need for more research studies.

Implications for Practice

Pregnancy presents a great opportunity for healthcare providers to screen women for IPV, as their care requires frequent office visits. Practitioners build therapeutic rapport with their obstetrical patients over the course of their pregnancies, often creating trusting relationships. With findings from this integrative literature review, practitioners will be better able to assess their patients for IPV. In my own practice as a family nurse practitioner (FNP) I will now be more knowledgeable in handling these types of patient situations. Healthcare providers report a reluctance to enquire about IPV due to knowledge deficits on the subject and not being sure which interventions to put in place for when patients screen positive. With evidence from this review practitioners will be able to provide education to their fellow practitioners on the importance to screen pregnant patients for IVP. There is a clear need for a standardized IPV screening tool during pregnancy and educational programs geared toward practitioners who will be treating this population of patients. Through IPV educational programs, practitioners will feel empowered to assess for IPV and will have the knowledge and capabilities to treat these patients accordingly.

Implications for Further Research

This project is relevant to contemporary nursing practice of the FNP as screening for IPV is a standard of care recommended by the USPSTF and other organizations; however, this literature review demonstrates a deficiency in health care provider preparedness, comfort, and consistency. Educational services and resources from an IPV professional, a valid screening tool with guidance from a written protocol, and transformation of the practice environment are needed to foster change [2]. This review exposed the need for a universal IPV screening tool for pregnant women. Universal screening can help identify IPV, provide women with the support they need, and in turn decrease IPV. Further high-quality evidenced based research is needed to assess which IPV screening tool would be best for the pregnant population. In addition, high-quality evidenced based research is also required to evaluate the effectiveness of interventions for IPV in the pregnant population [15].

The results of this review recommend that practitioners routinely screen their patients for IPV during each prenatal visit. Practitioners have a great opportunity during pregnancy to screen for IPV, as women frequent the office and therapeutic rapport and trust is established. The evidence states that screening pregnant women in a private and secure manner during prenatal visits can be beneficial in detecting IPV. Once IPV is identified practitioners can support and refer patients to the appropriate services to reduce or eradicate abuse. Additionally, this review suggests that practitioners should be educated on IPV and screening techniques. It is vital for practitioners to feel comfortable and confident about their knowledge on the subject, and to screen and provide resources for the women who screen positive. It is important for practitioners to serve as advocates for women suffering from IPV, by supporting them in their decisions and making the necessary referrals.