Management of a Patient who has Suffered Domestic Violence
Domestic violence, or intimate partner violence (IPV), is threatening or controlling behavior inflicted on a person by another person in the context of an intimate relationship. Intimate partner violence occurs in 1 in 4 women, and crosses socioeconomic and sexual preference boundaries.
Short-term, acute consequences of IPV include acute injuries to any part of the body. Catastrophic violence in early pregnancy may result in miscarriage. Blunt force abdominal trauma in the second or third trimester can result in fetal injury. Long-term consequences of IPV include chronic pain syndromes, neurologic disorders, gastrointestinal disorders, migraine headaches, post-traumatic stress disorder, depression, anxiety disorders, substance abuse, and suicide. IPV in pregnancy is associated with poor pregnancy weight gain, infection, substance use, low birth weight, preterm delivery, depression, and maternal and neonatal death. It is unclear if this association is a direct result of IPV, or related to maternal stress or tobacco and alcohol used for coping.
Women may not disclose IPV the first time they are asked. The US Preventive Services Task Force recommends screening women of reproductive ages for intimate partner violence. ACOG recommends screening all women for intimate partner violence as a part of preventive health care visits. Pregnant women should be screened at the first prenatal visit, at least each trimester, and at the postpartum visit. Screening may be performed electronically or face to face. The ACOG website and Committee Opinion have suggested screening tools. Maintaining confidentiality during screening is essential. The RADAR domestic violence intervention can be very useful:
- Routinely screen every patient
- Ask directly, kindly, nonjudgmentally
- Document your findings
- Assess the patient's safety
- Review options and provide referral
If IPV is disclosed, clinicians should assess the immediate safety of the patient and her children. Information on local shelters, hotlines, and other resources should be available in handout, pamphlet, or safety card format in the clinician’s office. Many women do not leave the relationship immediately for a variety of reasons including fear of retaliation from their partner, fear of the legal system, financial concerns, or shame. In order to be prepared if and when she does leave the relationship, though, a woman who reports domestic violence should not leave the office without a plan for her safety and the safety of her dependents. This safety plan should be created even if she does not plan to leave the abuser immediately. Elements of the safety plan should include packing a bag and storing it in a safe location, having copies or originals of personal documents ready, hiding extra sets of house and car keys, establishing a “code” with family and friends, and planning where to go.
Reproductive and sexual coercion refers to behavior intended to maintain control in a relationship by way or reproductive health, and it occurs to at least half of victims of IPV. This behavior includes attempts to impregnate a partner against her will, control pregnancy outcomes, coerce a partner into unprotected sex, or preventing effective contraception. Providers should counsel patients on harm-reduction strategies and facilitate initiation of tamper-proof contraceptive methods such as injectables, long-acting reversible contraception, or permanent sterilization to avoid unwanted pregnancy.
IPV of a minor is child abuse and reporting is mandated in all states. Laws for reporting IPV in an adult vary by state. State specific information is available on the CDC and futureswithoutviolence.org web sites. A woman may gain a sense of control over the situation if involved in the reporting process.
American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 518: Intimate partner violence. Obstet Gynecol. 2012 Feb;119(2 Pt 1):412-7. doi: 10.1097/AOG.0b013e318249ff74.
Chamberlain L, Levenson R. Addressing Intimate Partner Violence, Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic and Reproductive Health Care Settings. Produced by Futures Without Violence, formerly the Family Violence Prevention Fund. ©2012, 2nd edition. Can be downloaded at the following site: http://www.futureswithoutviolence.org/userfiles/file/HealthCare/reproguidelines_low_res_FINAL.pdf
US Preventive Services Task Force, Curry SJ, Krist AH, et. al, Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: US Preventive Services Task Force Final Recommendation Statement. JAMA. 2018 Oct 23;320(16):1678-1687. doi: 10.1001/jama.2018.14741.
American College of Obstetricians and Gynecologists. ACOG Committee opinion no. 554: reproductive and sexual coercion. Obstet Gynecol. 2013 Feb;121(2 Pt 1):411-5. doi: http://10.1097/01.AOG.0000426427.79586.3b.
Initial approval January 2015; Revised July 2016, November 2017 and May 2019.
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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.
Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The Foundation reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. The Foundation does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither the Foundation, the ABOG, SASGOG nor their respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.
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