ACCORDING to the Centers for Disease Control and Prevention (CDC) National Intimate Partner and Sexual Violence Survey, 32.4% of women in the United States have experienced physical violence by an intimate partner, and 19.1% have reported complete or attempted rape by their former or current partner. These statistics are only a sample of the number of women who suffer from intimate partner violence (IPV).

IPV (which is preferred over the term “domestic violence”) is the occurrence or threat of physical, verbal, sexual, emotional, or psychological abuse by a current or former partner or spouse. It occurs in all demographic and socioeconomic groups. Many women don’t report IPV and don’t seek help because they fear retribution by the attacker or feel that they’re somehow responsible.

Two distinctions are relevant to IPV that occurs with pregnancy: violence during pregnancy and sexual assault or reproductive coercion resulting in pregnancy. The circumstances can be devastating for both the woman experiencing the violence and her unborn child. According to the World Health Organization (WHO), when abuse occurs during pregnancy, it typically continues throughout the pregnancy and may persist postpartum. The WHO, CDC, and Healthy People 2020 agree that IPV is a primary health concern and a leading cause of traumatic death for pregnant women and their unborn children. (See Revealing study.)

Cycle of abuse

Research shows that IPV is cyclical and that all family or relationship dynamics are touched by it. Men raised in a home with IPV and those who were abused as children may become abusers themselves. According to the Family Violence Assessment and Intervention Guideline, a significant co-existence occurs between child abuse and IPV in families. Specifically, child abuse happens in 30% to 60% of homes with a history of IPV, and child abuse increases as IPV intensifies.

Nurses should be aware of common behaviors among abusers, especially since they may try to prevent healthcare professionals from speaking alone with the patient. Many abusers block their partners’ access to healthcare resources or insist on remaining with the woman during appointments and answering questions. They also may isolate their partners from friends and family, creating more dependence on the abuser. Intimidation and threats also are common and healthcare providers may note that an abused pregnant woman will demonstrate fear of upsetting her partner.

Many abusers control frequency and timing of sex, sometimes using force, and they may expose their pregnant partners to sexually transmitted infections or HIV. Reproductive coercion occurs when the abuser forces his partner to continue with an unwanted pregnancy, attempts to cause a miscarriage, or forbids voluntary sterilization and birth control.

Violence and pregnancy

Pregnant women, particularly those with an unplanned pregnancy, are more vulnerable to IPV than those who aren’t pregnant. A significant relationship exists between violence in pregnancy and maternal low self-esteem, anxiety, negative self-image, and depression. Research indicates that women who are abused during pregnancy are more likely to attempt suicide and to be diagnosed with depression or psychosis. They also are more likely to misuse alcohol and drugs during pregnancy. Women who experience IPV typically begin prenatal care later than women who aren’t abused, and they may frequently miss appointments. Pregnant women experiencing abuse may instead visit a provider for stress-related illnesses or complaints.

IPV during pregnancy has been associated with poor weight gain, infections, anemia, stillbirth, pelvic fractures, placental abruption, fetal injury, preterm labor and delivery, small-for-gestational age and low-birth-weight infants, and maternal or fetal death. Evidence also shows that pregnant women are more likely to die from trauma than their nonpregnant counterparts and are twice as likely to experience violent trauma. (See The smallest victims.)

IPV screening and assessment

Because clinical histories and physical findings will vary among patients and may not clearly point to abuse, nurses and providers should assess all pregnant women for IPV. The U.S. Preventive Services Task Force recommends that clinicians screen women of childbearing age for IPV at each visit and provide interventions and referrals to services as appropriate. The Association of Women’s Health, Obstetric and Neonatal Nurses states that universal IPV screening of all women should take place in a safe, private setting. The American College of Obstetricians and Gynecologists recommends screening for IPV during obstetric care beginning with the first prenatal visit, at least once per trimester, and at the postpartum checkup.

Some screening can be done using self-administered questionnaires, which clinicians then review. When screening is done face-to- face, nurses or providers should tell the patient that they screen all women, not just cases where they suspect IPV. In addition, they should highlight that the conversation is confidential other than what the state requires them to report. (See Screening resources.)

A confidential, trusting relationship between the patient and her provider is critical for accurate IPV reporting. If a woman divulges abuse, nurses and providers must ensure that she isn’t stigmatized or blamed. They should offer support, secure her immediate safety, and provide appropriate medical attention.

Signs and symptoms

Because women may not disclose information about their intimate relationships unless they feel safe, healthcare professionals should be alert to the signs and symptoms of abuse. The most common sign of physical abuse in pregnancy is bruising, particularly a combination of old and new bruises. They’re usually seen on the abdomen and back and also on the arms as a result of the woman’s attempts to shield her abdomen.

Other signs and symptoms include offering odd and/or inconsistent excuses for bruising; personality changes (low self-esteem in someone who previously was self-confident and outgoing); anxiety about pleasing her partner, getting home, or accounting for her time; missing work or school for no clear reason; depression; wearing clothing inappropriate for the season (long sleeves in the summer to cover bruising); and withdrawal from social settings. In addition, the woman’s partner may do all or most of the talking when they’re with others and may insist on answering medical questions when the patient seeks healthcare.

Cultural sensitivity

Screening and assessments should  be culturally sensitive. Note that some cultural norms may be more accepting of violent behavior, making women reluctant or fearful to speak about it. Nurses can help by developing a consistent, trusting rapport with patients.

Abusers isolate their victims from family and friends, and you may be the only person your patient can talk to about her abuse. Speak with her alone, without her partner. With compassion, and without judgment, let the patient know that you care, that she’s not alone, and that the abuse is not her fault. Ask her what she would like to see happen and how you can help. This empowers her in a situation where she’s been powerless. Be supportive, but don’t make decisions for her. Instead, offer possible solutions, present options, and talk through scenarios. If the patient chooses a path that worries you, let her know that you’re concerned about her safety and why. Make sure she has all the resources you can give her. Offer to call an advocacy program for the patient if she doesn’t want to or can’t do it herself and provide referrals to a safe place to stay and the National Domestic Violence Hotline at 1-800-799-SAFE (7233), which is available 24 hours a day.

If language is a barrier to accurate screening, and the services of a translator are required, a family member shouldn’t serve in that role. He or she may not translate accurately, the patient may not want to divulge private issues to the family member, and the translator may be the abuser. Instead use in-person or online medical translator services.

When IPV is suspected

When healthcare providers suspect IPV, they must first assess the patient’s safety. One tool is the lethality screen from the Lethality Assessment Program. Although the screen was designed for first responders, clinicians may find it helpful; the results can be shared with the woman to emphasize the seriousness of her situation.

The patient may be isolated from support systems and fear retribution, so nurses and providers should understand that exposing their knowledge of the abuse to the abuser, or to anyone else, may place her in more danger. Developing a safety plan is key. These plans typically include what a woman should do during a violent incident, how she can prepare to leave, and how to be safe in the residence she goes to. The Domestic Violence Resource Center has detailed information about safety planning at dvrc-or.org/safety-planning.

Maintain regular contact with the patient to assess her health and  safety. Ideally, the patient should be seen by the same team of providers and scheduled with extra time at each visit. The IPV screening results should be incorporated into the electronic health record, with secure access made available to the healthcare team, to ensure continuity of care.

Most states have mandatory reporting requirements, similar to child abuse laws, which require nurses and other healthcare professionals to report IPV to law enforcement or other regulatory agencies. Nurses must be familiar with their state’s mandatory IPV reporting rules, and they should explain them to patients. In addition, all nurses should participate in regular IPV training and competency validation.

When confidential relationships with healthcare providers are established, women can be guided and supported in their decision-making, referred to local agencies—including housing, law enforcement, social services, and help lines. (See Tools you can use.)

Nurses need to understand that women may not find breaking away from their abuser easy due to fear of retaliation or an inability to support themselves. Although we can empower patients, each woman’s passage to safety may require a different route. Our goal as nurses is to support women in their efforts.

Debra A. Hrelic is the RN-BSN program coordinator at the University of North Carolina Wilmington.

Selected references

American College of Obstetricians and Gynecologists. Committee opinion no. 518: Intimate partner violence. February 2012, reaffirmed 2019. acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Intimate-Partner-Violence

AWHONN position statement. Intimate partner violence. J Obstet Gynecol Neonatal Nurs. 2019;48(1):112-16. cdn.ymaws.com/www.awhonn.org/resource/resmgr/pdfs/positionstatements/IPV_Jan_19_JOGNN.pdf

Centers for Disease Control and Prevention. The National Intimate Partner and Sexual Violence Survey: 2010-2012 State Report. 2017. cdc.gov/violenceprevention/pdf/NISVS-StateReportBook.pdf

Deshpande NA, Kucirka LM, Smith RN, Oxford CM. Pregnant trauma victims experience nearly 2-fold higher mortality compared to their nonpregnant counterparts. Am J Obstet Gynecol. 2017;217(5):590.e1-e9.

Fanslow JL, Kelly P. Family Violence Assessment and Intervention Guideline: Child Abuse and Intimate Partner Violence. 2nd ed. New Zealand: Ministry of Health; 2016. health.govt.nz/system/files/documents/publications/family-violence-assessment-intervention-guideline-jun16_0.pdf

Menezes Cooper T. Domestic violence and pregnancy: A literature review. Int J Childbirth Educ. 2013;28(3):30-3.

Murray SS, McKinney ES, Holub K, Jones R. Foundations of Maternal-Newborn and Women’s Health Nursing. 7th ed. St. Louis, MO: Elsevier; 2019.

National Collaborating Centre for Women’s and Children’s Health (UK). Women who experience domestic abuse. In: Pregnancy and Complex Social Factors: A Model for Service Provision for Pregnant Women with Complex Social Factors. London: RCOG Press; 2010. ncbi.nlm.nih.gov/books/NBK62622/