19.11 Intimate Partner Violence

Intimate partner violence (IPV), also called domestic violence, refers to abuse or aggression that occurs in a romantic relationship with a current or former spouse or dating partner. IPV during pregnancy can take various forms, including physical, sexual, and emotional abuse. Consequences of IPV during pregnancy can be severe with adverse fetal and maternal outcomes such as preterm birth, low birth weight, fetal injury, maternal depression and anxiety, post-traumatic stress disorder (PTSD), and maternal and/or fetal death. Nurses play a crucial role in identifying women experiencing IPV during pregnancy and providing appropriate support.^[1]

Physical violence during pregnancy can cause injuries such as bruises, fractures, and head injuries. These injuries can have short-term and long-term effects on a woman’s health and well-being. For example, a fracture may cause chronic pain or limited mobility that can impact the mother’s ability to complete activities of daily living and/or care for the newborn after childbirth. Head injuries can result in long-term neurological damage, which may affect the mother’s cognitive abilities and mental health. Physical and/or sexual violence during pregnancy, especially abdominal or vaginal trauma, can cause vaginal bleeding, premature rupture of membranes, placental abruption, premature labor, fetal distress, and miscarriage.^[2]

Pregnant women who experience IPV are at increased risk of depression, anxiety, and PTSD. Depression is characterized by feelings of sadness and hopelessness and a loss of interest in activities that were once enjoyable. Pregnant women with depression may also experience sleep disturbances, changes in appetite, and difficulty concentrating. Anxiety is characterized by excessive worry and fear and can include symptoms such as panic attacks, irritability, sweating, shaking, shortness of breath, and difficulty sleeping. PTSD can occur after exposure to a traumatic event such as IPV and may cause flashbacks, nightmares, and feelings of intense fear and anxiety.^[3]

IPV during pregnancy is caused by a variety of individual, relationship, community, and societal risk factors. Understanding these factors can help nurses identify women who are at increased risk of experiencing IPV during pregnancy and develop effective interventions.

Individual risk factors for IPV include a history of experiencing IPV or those who are in an abusive relationship before becoming pregnant. Low levels of education or income can increase the risk of experiencing IPV during pregnancy, as well as low levels of social support from family members or friends. Women with low self-esteem may believe they deserve to be treated poorly or are not capable of leaving an abusive relationship due to financial concerns. Conversely, women who have previously successfully coped with stressful situations may be better able to identify and respond to the warning signs of IPV during pregnancy.^[4]

Women who have a partner with a history of IPV, substance use disorder, or unemployment are at increased risk of experiencing IPV during pregnancy. In some cases, the pregnancy itself may trigger or exacerbate IPV. Conversely, women who have effective communication skills and conflict-resolution skills may be able to manage relationship conflicts and disagreements in a constructive and nonviolent way and reduce the risk of IPV.^[5]

Women who live in communities with high rates of poverty, unemployment, and other adverse social determinants of health are at increased risk of experiencing IPV during pregnancy. Financial stress, lack of access to resources and services, and social isolation can contribute to the occurrence of IPV. Conversely, women who live in communities with strong social support networks, accessible and available health care, and IPV prevention programs may be less likely to experience IPV during pregnancy. For example, a local community center can provide women with a sense of connection and safety, as well as access to resources and services. IPV prevention programs may include public education campaigns, free or reduced fee legal services, counseling services, and emergency shelters.^[6]

Routine screening for IPV during pregnancy allows nurses and health care providers to identify risk factors for IPV early in pregnancy and implement interventions to prevent or mitigate adverse effects of IPV on maternal and fetal health. Screening may include verbal communication using open-ended questions, standardized questionnaires, or computer-assisted self-interviews. After establishing trust, rapport and a supportive environment, nurses can ask open-ended questions such as, “Do you feel safe at home?,” “Has anyone hurt you or made you feel afraid?,” or “Is everything going okay in your relationship?” to elicit information about possible IPV risk factors.^[7]

A commonly used standardized questionnaire for screening for IPV during pregnancy is the Hurt, Insult, Threaten, and Scream (HITS) screening tool. This tool scores the answers from 1-5 that clients provide to four questions, ranging from “never” to “frequently”^[8]:

• How often does your partner physically hurt you?
• How often does your partner insult you or talk down to you?
• How often does your partner threaten you with harm?
• How often does your partner scream or curse at you?

A score greater than 10 indicates a positive screen for IPV.^[9]

Computer-assisted self-interviews (CASI) are self-administered computer-based questionnaires used to screen for IPV during pregnancy. CASI may facilitate the disclosure of IPV risk factors due to an increased sense of privacy and confidentiality it provides.^[10]

Nurses should also be aware of potential signs of IPV during prenatal care, such as unexplained injuries or sudden changes in behavior.^[11]

Interventions for IPV during pregnancy should be tailored to the client’s needs and may include creating a safety plan, referral to counseling and community resources, and advocacy for legal assistance such as restraining orders. Safety planning involves developing a personalized plan to help women identify safe places to go in an emergency; making a plan to leave an abusive situation; and creating a safety network of trusted friends, family, or advocates.^[12] Additionally, nurses are considered mandated reporters and must follow state law in reporting concerns about other children or elderly individuals in the home who may also be experiencing abuse or neglect.

Read more information about IPV and safety plans in the “Intimate Partner Violence” section of the “Maladaptive Coping Behaviors” chapter.