Pregnancy: A time to break the cycle of family violence

In an effort to raise the awareness and detection of domestic violence among pregnant women, the Child Protection Center, a child advocacy center at Montefiore Medical Center in the Bronx, New York, instituted an education and screening program for pregnant and parenting women who were using the OB/GYN

Pregnancy may offer a unique window of opportunity to engage women in promoting behaviors and attitudes that could help them reevaluate a violent relationship. A service and support network offered by medical centers with child advocacy center programs could provide a model for social workers and medical providers to address the serious needs of abused children and battered parents.

THE CHILD PROTECTION CENTER

Since 1984 the Child Protection Center (CPC) has evaluated over 12,000 sexually abused, physically abused, and neglected children. Using a family-centered approach, the CPC also provides support and counseling to family members. The CPC uses a multidisciplinary team of medical providers, social workers, police officers, child protective services caseworkers and the District Attorney's office staff to reduce systems trauma to children by coordinating the rapid assessment, investigation, arrest, and prosecution activities for serious child abuse cases.

DOMESTIC VIOLENCE AND CHILD ABUSE CORRELATION

The CPC's records indicate that there is a cooccurrence of child abuse and domestic violence in 60 percent of the cases evaluated at the center (Child Protection Center, 1999). Growing awareness of the correlation calls for new measures to identify victims and provide resources. An American Psychological Association report (1996) estimated that each year 3.3 million children are exposed to violence against their mothers or female caretakers.

Case Examples

Cases in which both child abuse and domestic violence are present are evaluated at the CPC on a daily basis. Domestic abuse includes physical battering, emotional abuse, and threats of murder. Child abuse includes sexual abuse, physical abuse, and death. Case examples illustrate the severity of issues encountered by these CPC patients.

Example 1. During a psychosocial interview at the CPC, a woman described how her husband kicked her and hit her with a belt during her pregnancy. Her child was being evaluated for sexual abuse by the husband.

Example 2. A one-year-old infant suffered head trauma resulting from blunt impact. During an argument, the boyfriend of the mother picked up the baby and threw the baby at her. The infant's head hit a table; he suffered a fractured skull.

Example 3. During a dispute with a relative, a mother became so violently engaged that she did not realize that she had left her 18-monthold baby unattended in a bathtub until 15 minutes had passed. The child drowned during the argument.

Example 4. Teen-age parents enrolled in the CPC's parent education support group cited frequent violent altercations with their boyfriends or husbands during their pregnancy and after the birth of their children. Punching, slapping, pinching, scratching, and kicking behaviors were common. Degrading remarks about the woman's appearance and intellect were frequently cited.

Intervention in the OB/GYN Clinic

In 1997 the CPC received a grant from the UJA Federation of New York to improve identification of potential domestic violence victims. Because of the CPC's focus on the prevention of child abuse and an interest in the positive dynamic that the period of pregnancy may offer for effective intervention, an education, outreach, and screening program was initiated in the OB/GYN clinic.

Why OB/GYN?

Domestic violence is a major health concern in the United States. The American College of Obstetricians and Gynecologists (1998) defines domestic violence as a pattern of assaultive and coercive behaviors including physical, sexual, and psychological attacks, as well as economic coercion, used against current or former intimate partners. Violence does not stop during pregnancy. Norton, Peipert, Ziegler, Lima, and Hume (1995) and Jones and Horan (1997) noted that an estimated 7 percent to 17 percent of those screened for domestic violence admitted to abuse during pregnancy. Many providers of obstetric care do not screen every patient, so many domestic violence victims are undetected.

Pregnancy is a time when society offers support for a woman so that she may bring a healthy baby into the world. The trusting relationship that develops between the patient and the doctor and clinic social worker also can be a powerful vehicle for guiding behavioral change (Mayer & Liebschutz, 1998). The American College of Obstetricians and Gynecologists report (1998) provided a comprehensive overview of domestic violence that details the role that the provider plays in identification and intervention.

Three important factors helpful for success with leaving a battering situation are present during pregnancy. They are the following:

The expectant mother experiences personal motivation to make behavioral changes. This is usually associated with behaviors such as cessation of smoking, drinking alcohol, using substances, or eating healthier foods. Social workers can contribute to the woman's motivation to end a violent relationship and simultaneously provide access to resources and emotional support.

Regular access to medical care or social work providers is increased and available to mothers at risk during pregnancy. A unique relationship between the patient and provider is built during the pre- and postnatal period because of the frequency of exams. A disclosure of trouble in the home environment may occur if the OB/ GYN clinic is consistent with its inquiries regarding the woman's health, emotional status and her relationship with the father of the child.

Social resources are available to pregnant women that they may not be eligible for at another time. During pregnancy, women are eligible for services that include access to regular medical care through federally mandated provision of medical insurance, easier access to social work providers and mental health services, substance abuse services, food assistance, and child welfare programs.

IMPLEMENTATION OF FAMILY VIOLENCE SCREENING

The social work team of the CPC designed an education, screening, and referral program for patients using the OB/GYN clinic at the medical center. The process included conducting inservice training for the clinic staff on domestic violence issues, establishing a linkage system for the providers if abuse was disclosed, and engaging the patients and discussing their safety needs.

Addressing the Needs of a Latino Population Approximately 60 percent of the families using the CPC and other services of the medical center are Latino, predominantly Puerto Rican and Dominican. The CPC case manager conducting the screening is bilingual and culturally competent. Information in Spanish, including a Spanish-speaking hotline number, is available for the patients.

Addressing Safety Needs and Concerns of Pregnant Women

The CPC social work case manager conducts screening at the clinic three days a week. It is interesting to note that the patients usually arrive unaccompanied by their male counterparts. This factor differs from Emergency Department visits, during which the batterer often accompanies the victim who is receiving evaluation and medical services. Initiating a dialogue about personal safety and domestic violence is much easier in a setting where the woman is not fearful of the batterer's presence.

The case manager meets with every female patient and explains that part of the services offered by the CPC is to address the personal safety needs of the woman and her unborn or newborn child. Every woman is screened regardless of her current medical condition or the ages of her children.

The case manager's questions cover four topics: stress, fears, support systems, and safety plans. During the engagement effort, the women receive information about domestic violence risk assessment. The materials cover examples of domestic violence; information on the victims' rights, protections under the law, and the court process; and obtaining orders of protection; she also receives a palm card with a local hot-line number. The women are encouraged to share the information with others who might be involved in a violent relationship. Often the women are comfortable speaking about their friends or relatives who have endured domestic violence or are currently at risk. The case manager takes precautions not to push for a disclosure during the initial encounter; the goal is to generate awareness about support and resources for the women experiencing this trauma. Because the case manager returns to the clinic on a regular basis, there are other opportunities to continue the discussion. The clinic staff and the obstetrician are also available to answer questions during the examination. Examples of questions that are asked during the encounter include:

Stress: What stresses do you experience in your relationship? What is the most stressful aspect of your pregnancy? Do you feel safe in your relationship or marriage? Should the medical center be concerned for your safety or that of your children?

Fear: What happens when you and you partner disagree? Have you ever had a restraining order? Have you ever been threatened or physically hurt by your partner?

Support systems: Is someone in your family or a friend aware that you have or may be at risk of being physically hurt? If you were abused by your spouse or paramour do you think that you could tell them?

Safety plan: Have you ever thought about developing a safety plan? Do you have a safe place to go and money, clothes, credit cards that you could take with you if you were in danger? Would you like to develop a plan now?

The type of questions and their intensity are determined on an individual basis. The case manager also distributes her business card. The woman may have questions after she leaves the clinic.

EDUCATION FOR THE SOCIAL WORK AND MEDICAL PROVIDERS

During the study discussed, 150 physicians, certified nurse practitioners, certified midwives, social workers, emergency medical service providers, and medical center staff received training on identifying family violence. A helpful tool in this assessment effort is the Physician's Reference Card (1998) that was developed and distributed by the New York State Department of Health, Office for Prevention of Domestic Violence. The laminated card aids the social work and medical provider with step-by-step instructions that should be followed if abuse is identified in their practice.

The providers were directed to encourage the patient to talk about the abuse, to listen with a nonjudgmental attitude, and to validate the woman's feelings because domestic violence victims frequently are not believed. The providers were instructed on proper documentation of the patient's complaints and symptoms, with a detailed description of the injuries and an opinion as to the injuries' consistency with the patient's explanation. Color photographs should be taken. If the patient discloses that children in the household also are in danger, the card directs physicians on the State Central Registry reporting procedures. The patient's safety must be assessed before she leaves the medical setting. Appropriate treatment and referral must be provided. The hot-line numbers for Englishand Spanish-speaking callers are listed on the reference card.

Providers are encouraged to take special note of any injury during pregnancy, especially to the abdomen or breasts. Explanation by the patient that is inconsistent with the type of injury, psychological distress, depression, suicidal ideation, anxiety, or sleep disorders should be noted. Providers should be aware of a partner who seems overly jealous and overly protective or who will not leave the woman's side during the examination.

The OB/GYN clinic should have available the resources of their affiliated hospital and victims services agencies. By using a "team approach" such as that implemented at the CPC Child Advocacy Center, the provider becomes part of a multidisciplinary system of care and is not overwhelmed with the needs of the woman. Referrals and services can be accessed in an expedited manner.

RESULTS OF OUTREACH FOR FAMILY VIOLENCE SCREENING

During the period of July 1, 1998, through June 30, 1999, 858 patients at the OB/GYN clinic received information and were screened by the social work case manager. Through this initial outreach effort, 46 women were identified as currently involved in a domestic violence relationship and requested assistance. Twenty of these women disclosed physical abuse such as hitting and beating and hair pulling. Twenty-six women described emotional abuse, in which threatening and degrading remarks were experienced; the women's feelings of inadequacy often were exacerbated by their lack of control over the allocations of money earned and the inability to leave because of the partner's control over all financial resources.

Fifteen women stated that they knew a close friend or family member who was a victim of domestic violence and accepted information on their behalf. This response also could be interpreted as a hesitancy to identify themselves as victims at the time, as a result of their fear of the batterer. The initial screening and education session is a conscience-raising effort to alert women to their right to protection. Repeated assessments and support from their providers may aid women in eventual disclosure of the abuse. The social work and medical staff were encouraged to screen the patient during each follow-up visit with the intent of showing support and providing a safe opportunity for furthey disclosure. The network of provider services that is present because of the Child Protection Center's designation as a child advocacy center was beneficial in expediting referrals and resources for these women.

IMPLICATIONS FOR FUTURE PRACTICE

Social workers who are practicing in child advocacy centers must be aware of the correlation between child abuse and domestic violence. The clinical and forensic interviews conducted in these locations should explore all issues of family violence that are present in the home. The assessment should not focus exclusively on child abuse allegations, but on all violence factors that could place the children at risk of future abuse.

Social work and medical providers need to establish a trusting relationship in which the patient is comfortable discussing family violence concerns. Universal screening questions for family violence should be incorporated into all women's initial and on-going health care assessments. Social workers should be able to recognize symptoms of women at risk of family violence and cognizant of the grave implications facing the mother, unborn child, and the children in the home if battering goes undetected.

The need for training and coaching the social workers and medical providers should not be underestimated. Many of those who received the CPC initial training requested additional information. As word of the training spread through the medical center, other areas requested the training. Role play scenarios and coaching the providers in nuances of how to ask questions were indicated as very helpful.

Medical centers, out-patient clinics, and private OB/GYN offices must develop linkages with the local domestic violence agencies and child advocacy centers. Case management involving the disciplines of social work, medicine, law, police protection, and child protective services can expedite the safety of the family. Providers that are connected to these resources can more effectively identify and aid families in crisis.