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Who Gets Screened During Pregnancy for Partner Violence?
Kathryn Andersen Clark, MS;
Sandra L. Martin, PhD;
Ruth Petersen, MD, MPH;
Suzanne Cloutier, MS;
Deborah Covington, DrPH;
Paul Buescher, PhD;
Michelle Beck-Warden, MS
Arch Fam Med. 2000;9:1093-1099.
ABSTRACT
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Context Despite recommendations to screen prenatal care patients for partner violence, the prevalence of such screening is unknown.
Objectives To estimate the statewide prevalence of partner violence screening during prenatal care among a representative sample of North Carolina women with newborns and to compare women screened for partner violence with women not screened.
Design, Setting, and Participants This investigation examines data gathered through the North Carolina Pregnancy Risk Assessment Monitoring System, a random sample of more than 2600 recently postpartum women who were delivered of newborns between July 1997 and December 1998.
Main Outcome Measures Self-reports of violence, health service factors, and sociodemographic characteristics.
Analysis The prevalence of screening was computed, and odds ratios and 95% confidence intervals were used to examine bivariate and multivariable associations between being screened for partner violence and other factors.
Results Thirty-seven percent of women reported being screened for partner violence during prenatal care. Logistic regression analysis found that women were more likely to be screened if they received prenatal care from (1) a public provider paid by a public source; (2) a private provider paid by a public source; or (3) a public provider paid by a private source.
Conclusions These findings suggest that the majority of prenatal care patients in North Carolina are not screened for partner violence. Screening appears to be most highly associated with whether a woman is a patient in the public sector or the private sector, and with the source of payment for prenatal care.
INTRODUCTION
MANY WOMEN are victims of intimate partner violence before, during, and after pregnancy. Studies estimate that 4% to 26% of prenatal care patients experience intimate partner violence during the year before their current pregnancy and approximately 1% to 17% of prenatal care patients have been victims of violence during their current pregnancy.1-6 These estimates vary depending on the definition of violence, the method employed, and the clinical population studied. Partner violence may continue after the baby is born. One study found that 90% of previously abused postpartum women reported continued abuse by their partners after delivery.7 Pregnant women who are victims of intimate partner violence are at increased risk for substance abuse,5 inadequate prenatal care,8 inadequate weight gain,4 and may be at increased risk of poor birth outcomes.9-11 Furthermore, when pregnant and postpartum women experience partner violence, the subsequent health and well-being of their newborns may be adversely affected.12-13
In an effort to decrease the occurrence and the potential effects of partner violence, many professional health care organizations advocate implementation of universal screening for partner violence, followed by appropriate referrals of identified violence victims, as a routine part of prenatal care. For example, recommendations for screening have been made by the American Medical Association and the American College of Obstetrics and Gynecology.14-15 Previous research indicates that universal screening during pregnancy for partner violence can significantly increase the prevalence of disclosure.16-17 In addition, research suggests that women want their health care providers to ask about their experiences with violence.18-20 Despite these recommendations, cross-sectional data from individual clinics or specialties suggest that routine screening for partner violence is not consistently carried out in prenatal care settings. Such previous research has typically focused on screening rates by physician specialty and care setting. While these findings indicate that obstetrician-gynecologists are more likely to screen most of their patients for partner violence than other physician specialties,21 these clinic-based investigations suggest that prenatal care clinicians still do not routinely screen.22-23 In addition, 1 study found that public clinic settings are more likely to screen for partner abuse than other types of clinic settings.21 It is important to note that these studies rely on data collected from providers, rather than from the patients.
Because past studies have focused on the practice of screening pregnant women for partner violence within specific prenatal care clinics, it is unknown how generalizable these findings are to all prenatal care settings. Thus, the purpose of this study is to extend past research by examining prenatal screening for partner violence in a representative sample of postnatal women. Specifically, our study: (1) estimates the statewide prevalence of prenatal screening for partner violence among a representative sample of women with newborns in North Carolina; and (2) compares women who were screened for intimate partner violence with women who were not screened by health service factors, sociodemographic characteristics, health behaviors, and experiences of violence.
SUBJECTS AND METHODS
SUBJECTS
The North Carolina Pregnancy Risk Assessment Monitoring System (NC PRAMS) is an ongoing survey of North Carolina women who have recently given birth. The NC PRAMS is a cooperative project between the North Carolina State Center for Health Statistics, Raleigh, and the Centers for Disease Control and Prevention, Atlanta, Ga. Each month, approximately 200 women are randomly selected from the statewide birth certificate file of infants approximately 3 months after their date of birth. Out-of-state births to residents, in-state births to nonresidents, birth certificates missing the mother's last name, multiple gestations of 4 or more siblings, and births to mothers aged 12 years and younger are excluded. The monthly sample is stratified by birthweight so that a disproportionate number of women who had newborns with low and very low birthweights are selected. Women who are identified as Hispanic on the birth certificate are mailed questionnaires in English and Spanish.
ASSESSMENT
The NC PRAMS survey interview is a structured questionnaire distributed via mail to selected participants. There are several survey mailings that are followed by attempted telephone interviews for those who do not respond by mail.
There were a total of 162 737 live births in North Carolina between July 1, 1997, and December 31, 1998. During this period, 3542 women were included in the NC PRAMS sample. Two thousand six hundred forty-eight of these women (approximately 75%) responded to the study questionnaire, and of those, 2535 women (96%) had at least 1 prenatal visit, making them eligible for screening for partner violence during prenatal care. Among those women who received prenatal care, 2189 women (86%) had complete data available for this study analysis. Therefore, this study focuses on the 2189 women (62% of all women invited to be in the survey) with complete information on screening for partner violence, sociodemographic characteristics, health behaviors, health system factors, and intimate partner violence experiences. No differences were found between the women included in the analysis and those who were not included in terms of marital status, education level, race, ethnicity, employment status, receipt of assistance, maternal age, and previous children.
The interview contains questions concerning the identification of patients with histories of partner violence. In the literature, the definitions of screening vary widely. For the purpose of this article, screening is defined as a provider having talked with a woman during prenatal care about physical abuse by a husband or partner. For analysis purposes, a woman was considered to have been screened for partner violence if she indicated that during any of her prenatal care visits, a physician, nurse, or other health care worker talked with her about physical abuse to women by a husband or partner.
The interview also contained questions concerning sociodemographic characteristics, such as whether the women had any other children, maternal age, marital status, education, race/ethnicity, employment status, and receipt of state or federal aid (eg, welfare, public assistance, general assistance, food stamps, or Supplementary Security Income).
Questions concerning health system factors were also measured in the questionnaire, including timing of prenatal care initiation; use of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); source of prenatal care; and source of payment for prenatal care. For analysis purposes, payment for prenatal care was considered public if a woman reported payment by Medicaid alone or in conjunction with another source of payment. Payment was considered private if she reported payment by private insurance, a health maintenance organization, or personal income without Medicaid. Similarly, the source of prenatal care was considered public if a woman reported the primary source of care as a health department, community health center, hospital clinic, or other. The source of prenatal care was considered private if she responded that her primary source of care participated in a health maintenance organization.
Partner violence experiences were measured through a series of questions of the Abuse Assessment Screen—a psychometrically sound tool for screening prenatal care patients for violence.24 These questions were preceded by the following explanation: "These next questions are about physical abuse. Physical abuse means pushing, hitting, slapping, kicking, or any other way of physically hurting someone." A woman was then asked if her husband or partner physically abused her during the 12 months before she got pregnant and if her husband or partner physically abused her during her most recent pregnancy.
DATA ANALYSIS
The prevalence of screening for intimate partner violence was estimated according to the survey sampling procedures of NC PRAMS. Descriptive statistics, appropriately weighted, were used to examine whether a woman's screening status was associated with her sociodemographic characteristics, health system factors, and experiences of partner violence. These procedures were also used to examine bivariate relationships. Odds ratios and 95% confidence intervals are reported.
In addition, logistic regression analysis25 was used to model the probability of women being screened for partner violence related to their sociodemographic characteristics and health system factors. To consider the likely collinearity among the health system factors and select sociodemographic characteristics, bivariate relationships were assessed among employment status, receipt of public assistance, late entry into prenatal care, receipt of WIC during pregnancy, prenatal care provider type, and source of payment for prenatal care. Since public payment of prenatal care was highly associated with receipt of public assistance, late entry into prenatal care, and receipt of WIC during pregnancy, only the source of payment for prenatal care was kept for adjusted analysis. Because source of payment for prenatal care also was associated with the prenatal care provider, 3 indicator variables were created for the purpose of analysis: public prenatal care provider with public insurance, private prenatal care provider with public insurance, and public prenatal care provider with nonpublic insurance. The effect of each of these indicator variables was calculated using women with private care providers and private insurance as the reference group. More specifically, the probability of being screened for partner violence was modeled as a function of the sociodemographic factors (age, marital status, education level, race, and ethnicity), and the variable combining prenatal care provider type and source of payment. All calculations were performed using the SUDAAN software package (Research Triangle Institute, Research Triangle Park, NC),26 which takes into account the complex sampling methods employed in the survey.
RESULTS
Slightly more than one third of women (37%) reported having been screened during prenatal care for partner violence. Table 1 presents the overall characteristics of the study population. Thirty-two percent were unmarried, 19% had less than a high school education, 25% were African American, 4% were Hispanic, 8% were unemployed, 17% received public assistance, 44% previously had children, 14% were younger than 20 years, 54% were between the ages of 20 and 29 years, and 32% were aged 30 years or older.
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Table 1. Sociodemographic Characteristics of the Study Population*
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Bivariate analysis found that screening varied significantly according to the sociodemographic characteristics of the women (Table 2). Specifically, the odds of prenatal screening for partner violence among unmarried women were 3 times the odds of such screening among married women. Among women with less than a high school education, the odds of prenatal screening for partner violence were nearly 3 times the odds of screening among women who had graduated from high school. African American women had more than twice the odds of reporting prenatal screening for partner violence than women of other races. Women who were unemployed had nearly 3 times the odds of prenatal screening for partner violence than employed women. Similarly, women receiving some type of public assistance had nearly 3 times the odds of prenatal screening for partner violence than did women who did not receive public assistance. Women aged 20 to 29 years and those aged 30 years or older were less likely to be screened for partner violence than women younger than 20 years. No significant differences were found in the odds of prenatal screening for partner violence by parity or Hispanic ethnicity.
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Table 2. Bivariate Analysis of Prenatal Screening for Partner Violence and Sociodemographic Characteristics*
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Table 3 presents the differences in partner violence screening by each of the health systems factors determined by bivariate analysis. In particular, women who did not receive prenatal care during the first trimester had twice the odds of reporting prenatal screening for partner violence compared with women who did receive prenatal care during the first trimester of pregnancy. In addition, women who received WIC during pregnancy had 4 times the odds of prenatal screening for partner violence than women who did not receive WIC. Women whose prenatal care was paid for by a public source had nearly 4 times the odds of prenatal screening for partner violence than women whose prenatal care was not paid for by a public source. Finally, the odds of prenatal screening for partner violence among women who received their prenatal care from a public provider were more than 3 1/2 times the odds of such screening among women who did not receive prenatal care from a public provider.
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Table 3. Bivariate Analysis of Prenatal Screening for Partner Violence and Health System Factors*
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Overall, 4.9% of women reported intimate partner violence occurring during the year before pregnancy and 4.1% of women reported such violence occurring during pregnancy. However, more than half of women who reported partner violence before, during, or after pregnancy were not screened during pregnancy for partner violence. Thirty-nine percent of women who reported partner violence during the year before pregnancy also reported having been screened prenatally for partner violence, while 37% of women who did not experience partner violence during the year before pregnancy reported being screened (Table 4). Similarly, 45% of women who reported partner violence during pregnancy reported having prenatal screening for partner violence, whereas 37% of women who did not report partner violence during pregnancy reported having been screened. Finally, 44% of the women who reported partner violence during the time since delivery also reported having been screened, while 37% of women who did not experience partner violence since delivery reported prenatal screening for partner violence. None of the bivariate associations found between reported prenatal screening for partner violence and actual experiences of partner violence were statistically significant.
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Table 4. Bivariate Analysis of Prenatal Screening for Partner Violence and Experience of Partner Violence*
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Multivariable logistic regression found the strongest significant associations between screening for partner violence and 3 variables, namely, prenatal care provider status, insurance status, and race (Table 5). After controlling for sociodemographic characteristics, the odds of prenatal screening for partner violence among women who received prenatal care from a public provider and had their prenatal care paid for by a public source were more than 4 times the odds of such screening among women who had a private provider and private insurance. In addition, the odds of prenatal screening for partner violence among women who received prenatal care from a public provider but whose care was paid for by a private source had twice the odds of prenatal screening for partner violence than did women who had a private provider and private insurance. Furthermore, women who received prenatal care from a private provider but whose care was paid for by a public source had nearly twice the odds of prenatal screening for partner violence compared with women who had a private provider and private insurance. The only sociodemographic characteristic that remained statistically significantly associated with prenatal screening for partner violence after adjusting was race. The odds of prenatal screening for partner violence among African American women were nearly twice that of women who were not African American.
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Table 5. Results of the Logistic Regression Model of Prenatal Screening for Partner Violence as a Function of the Women's Sociodemographic Characteristics and Health System Factors*
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COMMENT
This study found that prenatal screening for partner violence is far from universal in North Carolina, with only 37% of all women reporting such screening. These findings are in line with clinic-based studies examining violence victimization screening. While better than some might expect, this prevalence of screening falls far short of the goal of 100% screening during prenatal care for partner violence.
The positive associations found between prenatal screening for partner violence and public payer and public sources for prenatal care suggest that public health care sources are providing more screenings for intimate partner violence than are other health care settings in North Carolina. This may be due to more provider training regarding screening for partner violence, less reluctance on the part of the clinician to address the issue of partner violence with the client population, and a perception that a referral system is more easily accessible through the public health care system. Another potential explanation for better prenatal screening for partner violence in public settings is implementation of the North Carolina Maternity Care Coordination program, which provides services to pregnant women through maternity care coordinators (MCCs), who are either trained nurses or clinical social workers. The majority of pregnant Medicaid-eligible women in North Carolina receive MCC services, which includes screening all clients for violence as part of the routine initial assessment. Another association found was that within nonpublic health care settings, women who have public insurance are screened more than women with private insurance. This may reflect a perception among providers that poorer women, even outside the public provider setting, are more likely to experience partner violence. In addition, MCCs are out-posted in some North Carolina counties from public care settings to private physician offices to provide services to pregnant women on Medicaid.
Many of the higher-risk sociodemographic characteristics, often experienced by patients who have public health care payers and/or providers, were associated with reported prenatal screening for partner violence, but these associations generally did not remain once prenatal care provider type and payer of prenatal care were controlled for. Only race remained statistically significantly associated with prenatal screening for partner violence after adjustment. This suggests that providers may perceive African American women to be at a higher risk of partner violence. Interestingly, race was not associated with experiencing partner violence before, during, or after pregnancy, after adjusting for sociodemographic characteristics, prenatal care provider type, and payer of prenatal care among this group of women.
It is interesting to note the greater likelihood of screening for partner violence reported by WIC participants. It is possible that some women may think that WIC visits during pregnancy are part of prenatal care and hence the reported screening for partner violence is occurring at WIC visits. Alternatively, women attending public prenatal care clinics may be more likely to enroll in WIC since referrals to WIC are routinely made and these services are often accessed at the same location. In either case, the findings of this study may be confounded if many of the women receiving public prenatal care were also receiving WIC.
The findings of this investigation must be viewed in light of the methodological constraints of the study. Prenatal screening for partner violence, as well as all other data, were self-reported by women retrospectively after delivery, and may be subject to various forms of recall and response bias. Thus, this study would have benefited from additional sources of information (eg, medical record documentation of screening). Furthermore, this research focused on a representative sample of women in North Carolina; thus, the study findings are not necessarily generalizable to women living in other states.
Despite the methodological limitations of the study, our findings may be useful to health care professionals and policy makers. This study suggests that barriers to screening may be specific to the clinical environment, connections with social service organizations, or even the types of providers (such as physicians, nurse practitioners, and certified nurse midwives).
This study demonstrates the magnitude of the improvement we must make in prenatal screening for partner violence to meet the recommendations for universal screening. Such a major change in the rate of screening for partner violence will be successful only if we provide resources to decrease the barriers to screening. This will need to consist of a multilevel approach of increased provider training, standardized and effective tools for screening, and appropriate and effective referral and interventions to decrease the occurrence of partner violence. This study also suggests that in North Carolina, screening for partner violence may be occurring based on the provider's perceived risk of violence to certain patients. Health care professionals may need more education about the pervasiveness of partner violence among women in all sociodemographic groups.
Further research is needed to determine what the public sector is doing to increase the rate of screening for partner violence so that similar rates of screening can be achieved in the private sector. In addition, information is needed to determine whether the screening methods used are actually helping women or whether more effective screening measures are needed.
AUTHOR INFORMATION
Accepted for publication September 14, 2000.
Funding for this report was provided in part by grant T32 HS00032 from the National Research Service Award Traineeship from the Agency for Healthcare Research and Quality sponsored by the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill. The NC PRAMS project, North Carolina Center for Health Statistics, Raleigh, is funded by a grant from the Centers for Disease Control and Prevention, Atlanta, Ga.
We gratefully acknowledge Beth Moracco, PhD, for her comments on earlier versions of the manuscript, as well as the reviewers for their comments.
Corresponding author and reprints: Kathryn Andersen Clark, MS, Department of Maternal and Child Health, University of North Carolina, Chapel Hill, CB #7400, Chapel Hill, NC 27599-7400 (e-mail: kathryn_clark{at}unc.edu).
From the Department of Maternal and Child Health (Ms Clark and Drs Petersen and Martin); Cecil G. Sheps Center for Health Services Research (Ms Clark and Dr Petersen); and the Department of Epidemiology (Ms Cloutier), University of North Carolina, Chapel Hill; Research Department, Coastal Area Health Education Center, Wilmington, and School of Medicine, University of North Carolina, Chapel Hill (Dr Covington); and State Center for Health Statistics, Raleigh, NC (Dr Buescher and Ms Beck-Warden).
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