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ORIGINAL RESEARCH |
From the1 Ohio State University College of Nursing, Columbus, Ohio; and 2Public Administration and Urban Studies, University of Akron, Akron, Ohio.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: Audio- and video-enhanced anonymous computer interviews were completed by women in 2 Level III postpartum units.
RESULTS: The sample was composed of 519 primarily African-American and white women who were educationally and economically diverse. Although 312 women (60.1%) reported being screened for violence by a health care provider at some point during their pregnancy, only 201 of 519 (38.7%) were asked by their prenatal care provider, with the remaining women reporting that they were screened during emergency room, triage visits, and labor and delivery admission. Of those who were screened by their prenatal care provider 195 of 201 (97%) women stated that they were not embarrassed, angry, or offended when assessed. Of the 66 women who were both abused and screened during their pregnancy, only 11 women disclosed abuse, with a resulting disclosure rate of 16.7%; however, 29 abused women who denied abuse to their health care provider stated that they would have changed their response if they had known that violence disclosure was not reportable in their state unless the victim was seriously injured or was wounded with a lethal weapon.
CONCLUSION: This study provides evidence that the great majority of pregnant women are not offended when screened for domestic violence and may increase their disclosure if they are told about state reporting mandates that preclude mandatory reporting for adults.
LEVEL OF EVIDENCE: II-3
The overall purpose of this study was to address the call for evidence-based research to support the use of domestic violence screening by clinicians. This aim was addressed by interviewing women themselves regarding their perceptions of, and experiences with, prenatal violence screening. Specific research questions were formulated to estimate:
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Undergraduate or graduate nursing students were trained as research assistants to recruit participants for this study. Operating under the assumption that women deliver randomly, research assistants recruited patients from a list of room numbers of eligible patients provided by nursing staff. Research assistants had no knowledge of potential participants’ names, ages, or other identifying data. Participants were recruited for this study when they were alone in their rooms.
Participants were interviewed in their private rooms or in a room adjacent to the postpartum unit with an anonymous audio-enhanced computer self-interview developed by the primary investigator (P.R.R.). The interview incorporated items developed by the researcher as well as those from standardized instruments using Authorware VI (Macromedia, San Francisco, CA). The interview sections of the computer program included informed consent, demographics, screening and intervention experiences, violence disclosure to health care providers, preferences or attitudes toward violence screening, pregnancy violence and violence severity screening, and an evaluation of the computer interview. The computer self-interview was used to address identified barriers to disclosure of abuse relating to reporting issues, loss of anonymity, and fear of repercussions from perpetrators for acknowledging abuse. The computer self-interview also allowed skips and branching of questions within the interview schedule (ie, women who identified that they were screened for violence by a health care provider were asked how they responded to the question; women who were not screened progressed to the next section of the interview). In addition, videos featuring the primary investigator and advocates from the local violence shelter were used throughout the interview to discuss informed consent, introduce topics, violence reporting issues, and to provide advocacy. The estimated time for completing the computer self-interview ranged from 30 to 90 minutes.
The Abuse Assessment Screen25,26 and the Women’s Experiences With Battering Scale27 were used to measure physical, sexual, and emotional abuse in this study. The Abuse Assessment Screen25,26 was developed by the National Research Consortium on Violence and Abuse in Women to detect physical, sexual, and emotional abuse during a specific period. In the screening instrument, women are requested to identify whether they have been "hit, slapped, kicked, punched, or otherwise physically hurt," whether they were or are afraid of anyone, and whether they had been forced into any sexual activities. McFarlane et al28 established construct validity of the Abuse Assessment Screen by comparing it with 2 instruments with established psychometric properties: the Index of Spouse Abuse29 and the Conflict Tactic Scales30 and deemed it to be "sensitive and specific"28 (p. 3176). Content validity was established by a group of 12 racially and ethnically diverse researchers who work in the area of violence against women.31 Soeken et al32 have established criterion-related validity with the Abuse Assessment Screen, the Index of Spouse Abuse, Conflict Tactic Scales, and Danger Assessment.33
Emotional abuse or psychological battering was determined by using 2 approaches: a single item indicator, "Do you feel that you were emotionally abused during your pregnancy?" and with the Women’s Experiences with Battering Scale.27 This scale was developed qualitatively from focus group interviews to address psychological vulnerability or battering, which includes the interpretations and meanings that women who are emotionally and physically abused assign to their experiences. The Women’s Experiences With Battering scale has been used in ethnically diverse samples, with Cronbach alpha coefficients ranging from .95 to .9934 in past research and had an alpha of .94 in this study. The Women’s Experiences With Battering Scale was found to discriminate accurately between known nonbattered women and battered women and has established construct validity.27 Participants were identified as abused in this study if they scored 20 or higher on the Women’s Experiences With Battering scale or answered affirmatively to any of the questions from the Abuse Assessment Screen or the item inquiring about emotional abuse.
Additional interview questions asked participants to identify whether they had been screened for violence during their pregnancies, their knowledge of state reporting laws, and whether they would have changed their responses to screening if they had been aware of the reporting laws, and their responses to violence screening.
Institutional review board permission was received from the university and the participating medical centers. Informed consent was provided after each participant discussed pertinent aspects of the study and informed consent with a research assistant and acknowledged their understanding of their rights as research participants at the beginning of the computer interview. The computer interviews ended for those individuals who indicated that they did not wish to proceed or did not understand their rights.
The sample size for this study was determined by estimating the population proportion for abuse with the formula n = [z2 p(1-p)]/h2, where z is the specified confidence coefficient for alpha = .05 (ie, 1.96 for a 95% confidence interval), p is the expected population proportion experiencing abuse (14%), and h is the allowable margin of error (5%).35 It was estimated that 370 women would need to be recruited to estimate the population measure for abuse with these specifications. A power analysis conducted in the program Sample Power 2 (SPSS Inc, Chicago, IL) specifying a population proportion of 14% and n = 180; indicated power more than 80%.
Participant responses were automatically entered into an Access (Microsoft Corp., Redmond, WA) database after they answered each question in the computer interview. The database was imported into SPSS 13 (SPSS Inc, Chicago, IL) for analysis. To account for the possibility of biased standard errors due to sampling from 2 hospitals (ie, clustering with hospitals), analyses were conducted using the SPSS 13 Complex Samples Add-On program (SPSS Inc). This program adjusts the standard errors to account for the clustering within sampling units (hospitals). Descriptive statistics and contingency table analyses using the 
2 test of differences were used to address the research objectives.
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RESULTS |
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The majority of the final sample participants were white (73.2%, standard error [SE] 5.5%) or African American (20.6%, SE 5.9%), and the majority of participants reported having some college experience. Income levels for this sample varied, with most women reporting annual incomes of $30,000 or more. Most women reported they were married to (66.5%, SE 11.3%) or living with (14.1%, SE 3.3%) the father of their neonate, received their prenatal care from an obstetrician–gynecologist (71.3%, SE 8.5%), and received their prenatal care at a private office or health maintenance organization (75.7%, SE 6.0%). The sample demographics reflected the county census and hospital demographics. Table 1 provides specific details of demographic variables.
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Overall, 91 women (17.6%, SE 5.4%) disclosed physical, sexual, or emotional abuse in the year before or during their pregnancies or both. The majority of women reported experiencing no abuse (81.9%, SE 5.5%), 5.4% (SE 1.6%) reported being abused only in the year before becoming pregnant, 3.7% (SE 1.5%) reported experiencing abuse only during their pregnancies, and 8.3% (SE 2.0%) reported experiencing abuse both before and during their pregnancies. There were no differences in the rates of reporting abuse by the location of care (public compared with private), age, or income.
Three hundred twelve (60.1% SE 3.2%) of the 519 women in our sample were screened for violence by their health care providers. Of those who reported being asked about violence, 201 (64.4% SE 3.3%) were screened by their prenatal care providers. The remaining 111 women (35.6%, SE 3.3%) were screened only during emergency department visits, triage visits, or admission to the labor and delivery unit. Of the 91 women who reported abuse to the computer self-interview, 67 (73.6% SE 0.8%) reported that they were asked about violence by their health care providers. Overall, this represents a screening rate of 38% by prenatal care providers.
The great majority of women screened by their prenatal care providers (97%, SE .01%, n = 195) stated that they were not embarrassed, angry, or offended when they were screened for domestic violence. There were no differences in acceptability of screening by health care setting (public compared with private) or income, but women aged younger than 21 years were more likely (P = .018) than those older than 21 years to say they were embarrassed by the violence questions (13%, SE 0.4%, n = 4 compared with 1.2%, SE 0.2%, n = 2), although the small total (n = 6) for this subgroup should be noted when interpreting this finding.
Of the 66 women who reported abuse on the computer self-interview and who were screened during their pregnancies, only 11 (16.7%, SE 1.5%) women stated that they acknowledged their abuse to their health care providers. There were no significant differences for this group (n = 66) in disclosure by age, race, income, prenatal care setting (public compared with private), or relationship with their neonate’s father.
Participants had minimal knowledge of state domestic violence reporting laws and professional guidelines for assessing for violence in this study. Although 233 (45%, SE 1.4%) women knew that health care providers in their state were required to document when the woman discloses that she is a victim of abuse in the medical record, only 167 (32%, SE 5.2%) knew that violence was reportable to authorities only if she had suffered serious harm or if a weapon such as a gun or knife had been used on her. On the other hand, 357 (68.8%, SE 0.2) participants knew that a patient’s medical record about abuse is kept confidential from other family members and insurance companies, and 296 (57%, SE 0.3%) were aware that information about abuse in a patient’s medical record could be used in court if the women requested it or if she was seriously hurt and the court requested the information. Moreover, 29 (5.6%, SE 2.4%) women stated that they would have changed their answer when screened if they knew the reporting laws. Of those 29 women, 15 (48%, SE 12.8%) women who denied abuse on the computer self-interview and to their health care providers would have changed their responses to their health care provider. The remaining 14 women (52%, SE 12.8%) indicated that they were abused to the computer self-interview and also stated that they would have changed their answer to their health care providers after learning about the confidentiality laws. Nine of the 14 women who stated that they would have changed their answers reported that they denied their abuse to their health care providers; the remaining 5 did not indicate their response when screened by skipping the question on the computer self-interview.
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DISCUSSION |
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The abuse disclosure rate of 16.7% in this study was disappointing. Abused women frequently state that they are concerned that their health care providers will report their abuse to the police and that this inhibits them from disclosing abuse when asked (Renker PR. Perinatal violence assessment: Teens’ rationale for denying violence when asked. J Obstet Gynecol Neonatal Nurs, in press). This study supports that concern by identifying that as many as 14 women who acknowledged abuse on the computer self-interview but denied it to their health care providers would have changed their answers if they had known that health care providers were not required to report violence unless a lethal weapon had been used or the woman was seriously injured. This means that the disclosure rate for the women who reported abuse to the computer self-interview and to their health care provider could have been as high as 38% if the women had been informed of confidentiality and reporting issues. In addition, another 15 women who denied abuse to the computer self-interview and their health care providers would have disclosed abuse to their health care providers when they were screened.
Although states vary widely in their reporting mandates, only 4 states had statutes requiring mandatory reporting of all injuries related to domestic violence in 2004.40 It is critical that health care providers become aware of their state’s domestic violence reporting laws and share that information before screening women for domestic violence during prenatal and well women care. Health care providers would benefit from attending training programs that not only address reporting mandates but also shed light on the complex issues involved with why women are hesitant to disclose abuse, frightened to leave an abusive relationship, and how the impact of normal developmental tasks associated with pregnancy affects woman’s decision making about violence issues during pregnancy and the postpartum.
Although the abuse disclosure rate in this study was low, it is important to note that past research has identified many conditions that may need to occur for women to disclose. For example, many women need to be asked about violence several times before they feel sufficiently comfortable to discuss their personal situations or are able to label their personal experiences as abuse.40 There is also evidence that women may listen to health care providers’ concerns regarding domestic violence during pregnancy and act later after their infants are born.41 Therefore, screening for violence may serve as both primary and secondary prevention for current and future abuse, even when women do not disclose during their pregnancies.
Violence screening by emergency, triage, labor and delivery, and social workers served as a safety net for abused women by assessing approximately 1 of 3 (n = 111) of the 318 women who were not screened by the prenatal health care providers in this study. In addition, although the overall screening rate (by prenatal care providers and other personnel during other health care exposures) was 61%, women reporting abuse to the computer self-interview were screened at the higher rate of 72.5%. This indicates that health care providers must have "red flagged" and increased screenings of those women who they suspected were abused. Unfortunately, the red flag approach did not work for 27.5% of women who were abused but not screened.
As with any study, there are limitations associated with this research. The interview measured women’s perceptions of being screening for domestic violence and asked only if they were asked verbally or in writing. Questions such as "Are you safe at home?" offered by their health care provider as a violence screening may not have been recognized as such by some of the participants. Although some patients may be comfortable with leading questions, others, including teens, may prefer direct questions (Renker PR. Perinatal violence assessment: Teens’ rationale for denying violence when asked. J Obstet Gynecol Neonatal Nurs, in press).38 It is also possible that abuse screening might have been focused on one type of abuse (for example, only physical abuse) and missed the specific type of abuse (sexual or emotional) that the patient was experiencing or was conducted at an initial patient visit early in the pregnancy when abuse was not occurring. These factors could account in part for the low disclosure rates to health care providers in this study. On the other hand, it is also possible that abuse prevalence rates identified in the postpartum computer self-interview were minimized in this study as women tend to reframe their prenatal experiences based on their birth outcomes. Since all of the women in this study were in satisfactory condition or better, it is possible that women chose to deny their prenatal violence experiences as they placed their hopes on a brighter future.
One of the statistical limitations in this study related to the inability to conduct detailed analyses of factors associated with patient disclosure of abuse. Cell sizes were small when examining differences between demographic subgroups—nonsignificant findings in these subanalyses may be reflective of Type II errors. A better understanding of the relationships between demographic variables such as age, income, race or ethnicity, and others and other relationships such as the effect of specific perpetrator characteristics associated with abuse disclosure would occur with larger (population-based) samples and would provide additional information to develop more effective screening protocols.
One of the strengths of this study is the economic diversity of the sample. Although the sample of over 500 women was composed primarily of African-American and white women, they came from various income, educational, and marital status backgrounds, adding important information about prenatal screening and violence experiences in private patients. Two additional findings that support the generalizability of the findings include the prevalence of abuse (17.6%) and abuse screening (39%) by prenatal care health providers, which were similar to those reported in previous research.6,7,16–18,27,28,31 The lack of statistically significant relationships between demographic variables such as age, income, marital status, and education with dependent variables of abuse and disclosure of abuse provides support for the thesis that a universal violence screening is appropriate during pregnancy.
Failure to assess and intervene for violence during prenatal care gives the message to abused women that their experiences are not valid and may lessen their need to leave an abusive relationship. Without accurate violence screening, it is very likely that abused patients’ physical and emotional health concerns will be misdiagnosed and mistreated, building further barriers to their safety and working relationships with health care providers. In this study, other clinicians screened many women who were not screened by their prenatal care providers. The sustained efforts of all of the members of the health care team are necessary to insure that all women have the opportunity to discuss their concerns about abuse with a professional.
The findings from this study address 1 of the previously cited barriers to universal screening for domestic violence, that of potential patient discomfort or offense when asked if they were experiencing abuse or violence in their lives, thus providing a needed element of evidenced-based practice in the area. In addition, the findings suggest that disclosure rates will increase in states without mandatory reporting if women are assured of confidentiality and highlight the need to reinforce reporting statutes to health care providers during domestic violence training programs and other continuing education forums. Although future research is needed to provide evidence for other aspects of universal screening, it is essential that the goal remain a priority for both researchers and clinicians.
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Footnotes |
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Corresponding author: Paula Rinard Renker, PhD, RNC, the Ohio State University College of Nursing, 342 Newton Hall, 1585 Neil Avenue, Columbus, Ohio 43210; e-mail: renker.6{at}osu.edu.
doi:10.1097/01.AOG.0000195356.90589.c5
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REFERENCES |
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