WHO recommendation on clinical diagnosis of intimate partner violence in pregnancy

WHO recommendation on clinical diagnosis of intimate partner violence in pregnancy

 

Recommendation

Clinical enquiry about the possibility of intimate partner violence (IPV) should be strongly considered at antenatal care visits when assessing conditions that may be caused or complicated by IPV in order to improve clinical diagnosis and subsequent care, where there is the capacity to provide a supportive response (including referral where appropriate) and where the WHO minimum requirements are met.

(Context-specific recommendation)

 

Publication history

First published: December 2016

Updated: No update planned

Assessed as up-to-date: December 2016

 

Remarks

  • Minimum requirements are: a protocol/standard operating procedure; training on how to ask about IPV, and on how to provide the minimum response or beyond; private setting; confidentiality ensured; system for referral in place; and time to allow for appropriate disclosure.
  • This recommendation is consistent with the 2013 publication Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines (1). The evidence on clinical enquiry was indirect (strong recommendation) and the evidence on universal screening was judged as being of low to moderate quality (conditional recommendation).
  • “Universal screening” or “routine enquiry” (i.e. asking all women at all health-care encounters) about IPV is not recommended. However, the WHO guidelines identify ANC as a setting where routine enquiry could be implemented if providers are well trained on a first-line response and minimum requirements are met (1).
  • Examples of conditions during pregnancy that may be caused or complicated by IPV include (1):

– traumatic injury, particularly if repeated and with vague or implausible explanations;

– intrusive partner or husband present at consultations;

– adverse reproductive outcomes, including multiple unintended pregnancies and/or terminations, delay in seeking ANC, adverse birth outcomes, repeated STIs;

– unexplained or repeated genitourinary symptoms;

– symptoms of depression and anxiety;

– alcohol and other substance use;

– self-harm, suicidality, symptoms of depression and anxiety.

  • The GDG agreed that, despite a paucity of evidence, it was important to make a recommendation due to the high prevalence and importance of IPV. ANC provides an opportunity to enquire about IPV among women for whom barriers to accessing health care may exist, and also allows for the possibility for follow-up during ANC with appropriate supportive interventions, such as counselling and empowerment interventions. However, the evidence on benefits and potential harms of clinical enquiry and subsequent interventions is lacking or uncertain.
  • A minimum condition for health-care providers to ask women about violence is that it must be safe to do so (i.e. the partner is not present) and that identification of IPV is followed by an appropriate response. In addition, providers must be trained to ask questions in the correct way and to respond appropriately to women who disclose violence (1).
  • Research on IPV is needed to answer the following questions:

– Which are the most effective strategies for identifying, preventing and managing IPV in pregnancy?

– Does asking routinely about violence impact on ANC attendance?

– Can interventions targeted at partners of pregnant women prevent IPV?

  • Detailed guidance on responding to IPV and sexual violence against women can be found in the 2013 WHO clinical and policy guidelines (1)
  • Context-specific recommendation refers to: recommended only in the context of rigorous research/ recommended only with targeted monitoring and evaluation/ recommended only in other specific contexts.

 

Background

Intimate partner violence (IPV), defined as any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship, is now recognized as a global public health issue. Worldwide, almost one third of all women who have been in a relationship have experienced physical and/or sexual violence by their intimate partner (2). Emotional abuse (being humiliated, insulted, intimidated and subjected to controlling behaviours such as not being permitted to see friends or family) also adversely impacts the health of individuals (2). IPV is associated with chronic problems in women, including poor reproductive health (e.g. a history of STIs including HIV, unintended pregnancy, abortion and/or miscarriage), depression, substance use and other mental health problems (2). During pregnancy, IPV is a potentially preventable risk factor for various adverse outcomes, including maternal and fetal death. Clinical enquiry about IPV aims to identify women who have experienced or are experiencing IPV, in order to offer interventions leading to improved outcomes. Some governments and professional organizations recommend screening all women for IPV rather than asking only women with symptoms (1).

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (3). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (4) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (5) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (6) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • For pregnant women (P), does routine clinical enquiry about IPV in ANC settings (I) compared with no IPV enquiry (C) increase the identification of IPV and improve maternal and perinatal outcomes (O)?

 

Evidence summary

The evidence on screening for IPV was derived from a Cochrane review that included two trials conducted in urban ANC settings in HICs (Canada and the USA), involving 663 pregnant women (7).

In one trial, 410 women were randomized before 26 weeks of gestation to a computer-based abuse assessment screening tool, with and without a provider cue sheet (giving the results of the assessment to the provider), prior to ANC consultation with a healthcare provider. In the other trial (a cluster-RCT), providers administered a face-to-face screening tool that screened for 15 risk factors, including IPV, to women between 12 and 30 weeks of gestation in the intervention clusters, while women in the control clusters received usual ANC.

Low-certainty evidence from the review suggests that abuse assessment screening may identify more pregnant women with IPV than those identified through usual ANC (2 trials, 663 women; OR: 4.28, 95% CI: 1.77–10.36).

Further information on evidence supporting this recommendation are available here.

 

Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Additional considerations

  • The review also pooled data on IPV screening versus no IPV screening from other health-care settings (involving pregnant and non-pregnant women), and the pooled effect estimate favoured screening to detect IPV (7 trials, 4393 women; OR: 2.35, 95% CI: 1.53–3.59).
  • Another Cochrane review evaluated interventions to prevent or reduce IPV (8). Uncertain evidence from one study suggests that pregnant women who receive IPV interventions (e.g. multiple counselling sessions) to prevent or reduce IPV may report fewer episodes of partner violence during pregnancy and the postpartum period (306 women; RR: 0.62, 95% CI: 0.43–0.88), but evidence on this and other outcomes is largely inconclusive.
  • Most of the review evidence comes from HICs where the prevalence of women experiencing IPV in the previous 12 months ranged from 3% to 6%. However, in many settings, particularly those where economic and sociocultural factors foster a culture more permissive of violence against women, the lifetime prevalence is higher than 30%. Notably, the prevalence among young women (under 20 years old) approaches 30%, suggesting that violence commonly starts early in women’s relationships (2).
  • Severe IPV in pregnancy (such as being beaten up, choked or burnt on purpose, being threatened with or having a weapon used against her, and sexual violence) (2) is more common among women who are in relationships that have also been severely abusive outside of pregnancy.
  • WHO’s clinical handbook on Health care for women subjected to intimate partner violence or sexual violence (2014) provides practical guidance on how to respond (9).
  • Clinical enquiry about IPV can be conducted face-to-face or by providing women with a written or computer-based questionnaire. Although the costs of implementing these methods can vary, they might be relatively low. Subsequent management and IPV support linked to the screening intervention, however, requires sophisticated training and can therefore have significant cost implications. The GDG considered that training and resources in low-resource settings might be best targeted towards first response to IPV rather than IPV screening.
  • IPV is highly prevalent in many LMICs and among disadvantaged populations (10,11). Effective interventions to enquire about IPV in disadvantaged populations might help to identify those at risk of IPV related adverse outcomes, and facilitate the provision of appropriate supportive interventions leading to improved equity. However, more evidence is needed.
  • Qualitative evidence from a range of settings on women’s views of ANC suggests that pregnant women would like to be seen by a kind and supportive health-care provider who has the time to discuss issues of this nature in a private setting (high confidence in the evidence) (12). However, evidence from LMICs suggests that women may be unlikely to respond favourably to cursory exchanges of information with providers who they sometimes perceive to be hurried, uncaring and occasionally abusive (high confidence in the evidence). In addition, some women may not appreciate enquiries of this nature, particularly those living in male-dominated, patriarchal societies, where women’s financial dependence on their husbands may influence their willingness to discuss IPV, especially if the health professional is male (12). From the providers’ perspective, qualitative evidence mainly from HICs suggests that providers often find it difficult to enquire about for IPV for the following reasons: they do not feel they have enough knowledge, training or time to discuss IPV in a sensitive manner; the presence of the partner acts as a barrier; they may have experienced IPV themselves; and they lack knowledge and guidance about the availability of additional support services (counselling, social work, etc.) (high confidence in the evidence). Providers highlight the midwife-led continuity of care (MLCC) model as a way of achieving a positive, trusting and empathetic relationship with pregnant women (moderate confidence in the evidence)
  • Following IPV clinical enquiry, complex, multifaceted, culturally specific interventions are required to manage IPV, which could be challenging in many low resource settings. However, emerging evidence from HICs shows that medium-duration empowerment counselling and advocacy/support, including a safety component, offered by trained health-care providers could be beneficial, and the feasibility of such interventions in LMIC settings needs investigation (1).

 

Research implications

The GDG identified this research priority related to this recommendation

  • Which strategies to enquire about and manage IPV are the most effective? Do interventions to enquire about IPV have an impact on ANC attendance? Can interventions focusing on partners prevent IPV? Does enquiry about IPV (with appropriate referral) have an impact on maternal and perinatal outcomes?

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Violence against women

 

References

  1. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: World Health Organization; 2013 (http://apps.who.int/rhl/ guidelines/9789241548595/en/, accessed 29 September 2016).
  2. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization; 2013 (http://www.who.int/reproductivehealth/ publications/violence/9789241564625/en/, accessed 29 September 2016).
  3. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  4. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  5. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016). 17. DECIDE [website].
  6. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
  7. O’Doherty L, Hegarty K, Ramsay J, Davidson LL, Feder G, Taft A. Screening women for intimate partner violence in healthcare settings. Cochrane Database Syst Rev. 2015;(7):CD007007.
  8. Jahanfar S, Howard LM, Medley N. Interventions for preventing or reducing domestic violence against pregnant women. Cochrane Database Syst Rev. 2014;(11):CD009414.
  9. Health care for women subjected to intimate partner violence or sexual violence: a clinical handbook. Geneva: World Health Organization; 2014 (WHO/RHR/14.26; http://www.who.int/ reproductivehealth/publications/violence/vawclinical-handbook/en/, accessed 26 October 2016).
  10. Abramsky T, Devries K, Kiss L, Francisco L, Nakuti J, Musuya T et al. A community mobilization intervention to prevent violence against women and reduce HIV/AIDS risk in Kampala, Uganda (the SASA! Study): study protocol for a cluster randomised controlled trial. Trials. 2012;13:96. doi:10.1186/1745-6215-13-96.  
  11. Krishnan S, Subbiah K, Chandra P, Srinivasan K. Minimizing risks and monitoring safety of an antenatal care intervention to mitigate domestic violence among young Indian women: The Dil Mil trial. BMC Public Health. 2012;12:943. doi:10.1186/1471-2458-12-943
  12. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392.

 

Citation: WHO Reproductive Health Library. WHO recommendation on the method for clinical diagnosis of intimate partner violence in pregnancy (December 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.