Case Study

A 22-year-old primigravid woman at 20 weeks' gestation presents to your office with her boyfriend for a routine obstetric examination. She has had an uneventful pregnancy. She states that things are “okay” at home, even though she was laid off from her job just before finding out that she was pregnant. Although the pregnancy was not planned, she is excited to be a mother. Because intimate partner violence (IPV) is common in the United States but often goes undetected, you decide to screen for possible signs of abuse.

Case Study Questions

1. According to the U.S. Preventive Services Task Force (USPSTF), which one of the following statements about screening for IPV is correct?

   A. Evidence shows that available screening instruments cannot accurately identify current or past abuse or increased risk of abuse.

   B. The Hurt, Insult, Threaten, Scream (HITS) instrument consists of four questions, can be used in a primary care setting, and is available in English and Spanish.

   C. The USPSTF found adequate evidence to recommend screening at-risk women at yearly intervals.

   D. Slapped, Threatened, and Throw (STaT) is a clinician-administered, three-item instrument that was tested in a high-risk obstetric clinic.

2. If screening results show that this patient has experienced IPV, she is at risk of which of the following?

   A. Preterm birth.

   B. Low birth weight.

   C. Depression.

   D. Decreased gestational age.

3. Which one of the following statements about interventions for IPV is correct?

   A. Adequate evidence shows that screening and interventions for IPV moderately increase the risk of harm to the individual.

   B. The USPSTF concluded with moderate certainty that screening women of childbearing age for IPV has no benefit.

   C. Interventions for IPV supported by the evidence include counseling, home visits, information cards, referrals to community services, and mentoring support.

   D. Studies show that only IPV interventions provided by social workers are effective.

Answers

1. The correct answer is B. There is adequate evidence that available screening instruments can identify current and past abuse or increased risk of abuse. Several instruments used in more than one study were found to be highly sensitive and specific. Those with the highest levels of sensitivity and specificity for identifying IPV are HITS; Ongoing Abuse Screen/Ongoing Violence Assessment Tool (OAS/OVAT); STaT; Humiliation, Afraid, Rape, Kick (HARK); Modified Childhood Trauma Questionnaire–Short Form (CTQ-SF); and Woman Abuse Screen Tool (WAST). The HITS instrument includes four questions, can be used in a primary care setting, and is available in English and Spanish. It can be self- or clinician-administered. HARK is a self-administered four-item instrument. STaT is a three-item self-report instrument that was tested in an emergency department setting. The USPSTF found no evidence on appropriate intervals for screening. It should be noted, however, that a major limitation of the evidence on screening is the lack of an established first-line method; all of the studies compared the screening instrument with a second instrument that was usually validated and often more detailed.

2. The correct answers are A, B, C, and D. Possible health consequences of IPV, in addition to injury and death, include sexually transmitted diseases, pelvic inflammatory disease, unintended pregnancy, chronic pain, neurologic disorders, gastrointestinal disorders, migraine headaches, and other disabilities. IPV in pregnant women is also associated with preterm birth, low birth weight, and decreased gestational age. Individuals experiencing IPV often develop chronic mental health conditions, such as depression, posttraumatic stress disorder, anxiety disorders, substance abuse, and suicidal behavior.

3. The correct answer is C. The USPSTF found adequate evidence that effective interventions for IPV can reduce violence, abuse, and physical or mental harms for women of reproductive age. Evidence from randomized trials supports a variety of interventions, including counseling, home visits, information cards, referrals to community services, and mentoring support. Depending on the type of intervention, these services may be provided by clinicians, nurses, social workers, nonclinician mentors, or community workers. Counseling generally includes information on safety behaviors and community resources. In addition to counseling, home visits may include emotional support, education on problem-solving strategies, and parenting support. The USPSTF also found adequate evidence that the risk of harm to the individual from screening or interventions is no greater than small. Of all the studies assessing potential harms, there were no significant differences between screening versus no screening and intervention versus nonintervention groups. Therefore, the USPSTF concluded with moderate certainty that screening women of childbearing age for IPV has a moderate net benefit.