Cueing Prenatal Providers: Effects on Discussions of Intimate Partner Violence

doi:10.1016/j.amepre.2007.09.029

American Journal of Preventive Medicine

Volume 34, Issue 2, February 2008, Pages 134-137

https://doi.org/10.1016/j.amepre.2007.09.029 Get rights and content

Background

Intimate partner violence (IPV) during pregnancy poses a significant health risk to the mother and developing fetus. Practice guidelines recommend that prenatal providers screen for and counsel their patients about IPV, yet many physicians express reluctance or discomfort regarding such discussions. The Health in Pregnancy (HIP) computer program was designed to improve prenatal providers’ counseling about behavioral risks.

Methods

English-speaking women 18 years or older, less than 26-weeks pregnant, and receiving prenatal care at one of the five participating clinics in the San Francisco area, were randomized in parallel groups in a controlled trial (June 2006–present; data analyzed June 2007). Participants reporting one or more risks were randomized to intervention or control in stratified blocks. Providers received summary “cueing sheets” alerting them to their patient’s risk(s) and suggesting counseling statements.

Results

Thirteen percent (37/286) of the sample reported current IPV. Provider cueing resulted in 85% of the IPV-intervention group reporting discussions with their provider, compared to 23.5% of the control group (p<0.001).

Conclusions

IPV discussions were influenced strongly by cueing providers. Provider cueing is an effective and appropriate adjunct to routine risk counseling in prenatal care.

Introduction

Pregnancy is a critical time to address intimate partner violence (IPV), a significant risk to the health of both the mother and developing fetus. IPV is pervasive among nonpregnant women,¹ and research has found that 4%–20% of pregnant women experience IPV.2, 3, 4 Violence perpetrated against a pregnant woman increases her risk for preterm labor, chorioamniotitis,⁵ delivering a low-birthweight infant,6, 7 and homicide.8, 9 Accordingly, the American College of Obstetricians and Gynecologists (ACOG) recommends routine screening for violence during pregnancy.¹⁰

Physicians are often the most important source of health information,11, 12, 13, 14, 15, 16 and advice messages from physicians can be powerful motivators for change.¹⁷ Unfortunately, although concerned about violence in the lives of their patients, prenatal providers frequently are reluctant to screen for and counsel about violence.¹⁸ Barriers to consistent screening and counseling include discomfort with the topic, fear of offending the patient, and a sense of powerlessness.¹⁹

Provider cueing mechanisms, however, either in the medical record or as computerized reminders, have increased screening for and counseling about other risks, especially smoking.20, 21, 22, 23 Similar cueing mechanisms may help providers overcome their barriers to discussing IPV by supporting and simplifying their role in initiating the discussion; by presenting the provider with the patient’s risk profile and possible counseling statements, the cueing mechanism can guide the provider through the conversation, minimizing the discomfort that the provider might otherwise feel without such instruction.

The Health in Pregnancy (HIP) computer program was developed to support and simplify prenatal providers’ efforts to screen and counsel their patients about risks. This study, embedded in a larger, randomized trial of patient risks and clinical outcomes, assessed the impact of provider cueing on patient–provider discussions about IPV, as compared to smoking.

Section snippets

Methods

In June 2006, a randomized, controlled trial was launched to assess the effectiveness of the HIP program in five prenatal clinics in the San Francisco Bay Area. Participants were English-speaking women 18 years or older, less than 26-weeks pregnant, and receiving prenatal care at one of the participating clinics. The participants represent a convenience sample; they were the eligible pregnant women present in the clinics’ waiting rooms on the days (and hours) when the research assistants were

Results

Between June 2006 and June 2007, 286 pregnant women completed a risk assessment (Figure 2). Most women (223; 78%) reported no risks and were not randomized; 63 women (22%) reported one or more risks and were assigned to intervention or control. IPV was the most frequently reported risk (n=37), followed by smoking (n=34). Risks were not mutually exclusive; twelve participants reported both IPV and smoking. Six participants reported drug use, and three reported alcohol use. In order to focus on

Discussion

This study identified potentially important differences in provider behaviors as a result of cueing based upon pre-visit assessments. Similar high prevalences of IPV (13%) and smoking (12%) were found in the sample of pregnant women, and providers were very willing to discuss smoking with their patients. With provider cueing, 100% of smokers in the intervention group had discussions of the risk with their provider. Even without provider cueing, 60% of the control group had discussions about

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The impact of screening for social risks on OBGYN patients and providers: A systematic review of current evidence and key gaps
2023, Journal of the National Medical Association
Increasingly, policymakers and professional organizations support screening for social assets and risks during clinical care. Scant evidence exists on how screening impacts patients, providers, or health systems.
To systematically review published literature for evidence of the clinical utility of screening for social determinants of health in clinical obstetric and gynecologic (OBGYN) care.
We systematically searched Pubmed (March 2022, 5,302 identified) and identified additional articles using hand sorting (searching articles citing key articles (273 identified) and through bibliography review (20 identified)).
We included all articles that measured a quantitative outcome of systematic social determinants of health (SDOH) screening in an OBGYN clinical setting. Each identified citation was reviewed by two independent reviewers at both the title/abstract and full text stages.
We identified 19 articles for inclusion and present the results using narrative synthesis.
The majority of articles reported on SDOH screening during prenatal care (16/19) and the most common SDOH was intimate partner violence (13/19 studies). Overall, patients had favorable attitudes towards SDOH screening (in 8/9 articles measuring attitudes), and referrals were common following positive screening (range 5.3%-63.6%). Only two articles presented data on the effects of SDOH screening on clinicians and none on health systems. Three articles present data on resolution of social needs, with inconsistent results.
Limited evidence exists on the benefits of SDOH screening in OBGYN clinical settings. Innovative studies leveraging existing data collection are needed to expand and improve SDOH screening.
Intimate partner violence and pregnancy: screening and intervention
2017, American Journal of Obstetrics and Gynecology
Citation Excerpt :
The studies may have differed slightly in how the intervention was delivered, but all were based on the empowerment model that includes education and safety planning. Two studies used a video to introduce the educational piece and then followed with the brief empowerment counselling including safety planning.25,29 The interventions that differed from those mentioned previously were the Zlotnick study that implemented 4 60 minute interpersonal psychotherapy sessions and 2 that used home visiting, but the actual intervention addressing intimate partner violence was unclear.30-32
In the first part of this review, we provided currently accepted definitions of categories and subcategories of intimate partner violence and discussed the prevalence and health impacts of intimate partner violence in nonpregnant and pregnant women. Herein we review current recommendations for intimate partner violence screening and the evidence surrounding the effectiveness of intimate partner violence interventions. Screening for intimate partner violence may include exclusively identification of victims of intimate partner violence or both the identification of and intervention for victims. Until recently, many professional organizations did not recommend universal screening for intimate partner violence because of a lack of evidence of effectiveness of screening, lack of evidence demonstrating that screening is not harmful, and/or a lack of consensus regarding the most effective screening tool. The lack of evidence supporting an intervention posed an additional barrier to screening. The American College of Obstetricians and Gynecologists has been a staunch advocate for universal intimate partner violence screening, even when other groups either did not endorse screening or recommended it only for high-risk women. Recent published data confirm that screening is more reliable than usual care in identifying victims of intimate partner violence, both during pregnancy and in nonpregnant women. Likewise, recent published data show that there are no apparent harms of screening for intimate partner violence and that the act of screening may have an empowering effect on women and improve their relationship with and trust in their health care providers. Despite these findings, the implementation rate of intimate partner violence screening remains low. Most encouraging are the recent data showing that interventions performed after screening for intimate partner violence are effective in reducing depression symptoms and episodes of violence as well as improving some outcomes of pregnancy. Although there remains a lack of consensus regarding which screening tool may be the most effective, we exhort all obstetrician-gynecologists to screen all women for intimate partner violence at regular intervals and to familiarize themselves with available community resources to assist those women who have been identified as experiencing intimate partner violence through screening.
The unique needs of pregnant, violence-exposed women: A systematic review of current interventions and directions for translational research
2017, Aggression and Violent Behavior
Citation Excerpt :
These seven studies evaluated ten different intervention programs. Of these programs, half were single-session screening, advocacy, or counseling services aimed at support, psychoeducation, and promoting safety behaviors (Calderón, Gilbert, Jackson, Kohn, & Gerbert, 2008; Cripe et al., 2010; Humphreys, Tsoh, Kohn, & Gerbert, 2011; McFarlane, Soeken, & Wiist, 2000; Tiwari et al., 2005). Results indicated that provider cuing of the patient led to an increase in discussing IPV during prenatal care (85% of intervention group versus 23.5% of control group, p < 0.001), but whether or not these conversations resulted in reduced rates of victimization was not evaluated (Calderón et al., 2008; Humphreys et al., 2011).
Intimate partner violence (IPV) is, unfortunately, a common lifetime experience for women, with heightened risk of exposure during pregnancy. IPV exposure in pregnancy is associated with serious physical and mental health problems in the perinatal period, as well as detrimental effects on the health and well-being of the developing infant. The objectives of the current review are to: (1) present representative literature on the effects of IPV in pregnancy, (2) conduct a systematic review of existing interventions for IPV-exposed pregnant women and (3) provide recommendations for future translational research in this area. The review indicated that despite the broad range of negative effects associated with IPV exposure during pregnancy, interventions are scarce and largely limited to crisis intervention approaches. Available interventions seeking to address broader or intergenerational effects of violence are limited in scope, and effectiveness data are preliminary in nature. As such, there is a great need for theory-based interventions that address women's complex needs, including specific developmental necessities of both the pregnant woman and her child (e.g., breastfeeding, early parenting, infant care). Incorporating these elements within a strengths-based paradigm may also decrease stigma related to IPV and facilitate empowerment and self-efficacy for this at-risk group.
Improving diet and exercise in pregnancy with Video Doctor counseling: A randomized trial
2011, Patient Education and Counseling
To determine if an interactive, computerized Video Doctor counseling tool improves self-reported diet and exercise in pregnant women.
A randomized trial comparing a Video Doctor intervention to usual care in ethnically diverse, low-income, English-speaking pregnant women was conducted. Brief messages about diet, exercise, and weight gain were delivered by an actor-portrayed Video Doctor twice during pregnancy.
In the Video Doctor group (n = 158), there were statistically significant increases from baseline in exercise (+28 min), intake of fruits and vegetables, whole grains, fish, avocado and nuts, and significant decreases in intake of sugary foods, refined grains, high fat meats, fried foods, solid fats, and fast food. In contrast, there were no changes from baseline for any of these outcomes in the usual care group (n = 163). Nutrition knowledge improved significantly over time in both groups but more so in the Video Doctor group. Clinician–patient discussions about these topics occurred significantly more frequently in the Video Doctor group. There was no difference in weight gain between groups.
A brief Video Doctor intervention can improve exercise and dietary behaviors in pregnant women.
The Video Doctor can be integrated into prenatal care to assist clinicians with effective diet and exercise counseling.
Increasing Discussions of Intimate Partner Violence in Prenatal Care Using Video Doctor Plus Provider Cueing: A Randomized, Controlled Trial
2011, Women's Health Issues
Citation Excerpt :
The current report focuses on the HIP program IPV intervention and its impact on patient–provider discussions of IPV at two consecutive monthly prenatal routine visits for the 50 participants who reported ever experiencing IPV. In a prior publication, we reported baseline data from the first 37 of these participants who self-reported IPV risk at the baseline assessment (Calderon, Gilbert, Jackson, Kohn, & Gerbert, 2008). In addition, 14 of these participants who reported both IPV risk and tobacco use at baseline were included in another publication that reported the impact of the Video Doctor plus Provider Cueing intervention for smoking-related advice and smoking outcomes (Tsoh, Kohn, & Gerbert, 2010).
To report the effectiveness of a prenatal intervention and to provide evidence that prenatal visits provide an opportune time for health assessment and counseling with abused women.
Fifty ethnically diverse pregnant women who presented for routine prenatal care and who also reported being at risk for intimate partner violence (IPV) were recruited to the study. Participants were assigned to either usual care or the Video Doctor plus Provider Cueing intervention. At baseline and 1 month later at another routine prenatal visit, intervention group participants received a 15-minute Video Doctor assessment and interactive tailored counseling. Their providers received a printed Cue Sheet alert and suggested counseling statements.
Participants in the intervention group were significantly more likely to report provider–patient discussions of IPV compared with participants receiving usual care at baseline (81.8% vs. 16.7%; p < .001) and at the 1-month follow-up (70.0% vs. 23.5%; p = .005). Summing the number of patient–provider discussions across the two visits at baseline and 1 month later, intervention participants were significantly more likely to have IPV risk discussion with their providers at one or both visits (90.0% vs. 23.6%; p < .001) compared with the participants who received usual care. When specifically asked about the helpfulness of these IPV-related discussions, 20 out of 22 (90.9%) participants rated the discussion as helpful or very helpful at baseline and all 18 (100%) participants rated the discussion as helpful or very helpful at the 1-month follow-up.
Video Doctor plus Provider Cueing intervention significantly increases the likelihood of provider–patient IPV discussion with pregnant women with a history of abuse.
Identifying the barriers faced by obstetricians and registrars in screening or enquiry of intimate partner violence in pregnancy: A systematic review of the primary evidence
2024, Australian and New Zealand Journal of Obstetrics and Gynaecology

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Brief reportCueing Prenatal Providers: Effects on Discussions of Intimate Partner Violence

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Am J Obstet Gynecol

Am J Prev Med

Am J Obstet Gynecol

J Midwifery Womens Health

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Prev Med

Prevalence of intimate partner abuse in women treated at community hospital emergency departments

JAMA

Prevalence of violence against pregnant women

JAMA

Violence and reproductive health: current knowledge and future research directions

Matern Child Health J

Prevalence of selected maternal and infant characteristics, Pregnancy Risk Assessment Monitoring System (PRAMS), 1997

MMWR CDC Surveill Summ

Physical and nonphysical partner abuse and other risk factors for low birth weight among full term and preterm babies

Am J Epidemiol

Psychosocial risk factors: perinatal screening and interventionACOG Committee Opinion No. 343

Obstet Gynecol

Healthier lifestyles: how to motivate older patients to change

Geriatrics

A study of preventive health attitudes and behaviors in a family practice setting

J Fam Pract

Brief report
Cueing Prenatal Providers: Effects on Discussions of Intimate Partner Violence