Question 3: How well do the interventions reduce exposure to IPV, morbidity, or mortality in women with positive screens?
Interventions improve outcomes, according to several studies. One good-quality RCT comparing prenatal behavioral counseling by psychologists or social workers with usual care found that the intervention led to decreased IPV up to 10 weeks’ postpartum and improved birth outcomes. These included a reduction in preterm births, increased mean gestational age, and decreased rates of very low birth weight, although the difference for very low birth weight was not statistically significant.
One fair-quality trial comparing home visitation by paraprofessionals with usual care for postpartum women led to lower rates of IPV for those in the home visitation group 3 years after the intervention.
Another study compared a counseling intervention with usual care for women who had reported recent IPV. The intervention led to a decrease in pregnancy coercion—being physically or verbally threatened with pregnancy or prevented from using contraception—and an increase in the likelihood of ending an unsafe relationship.
Two trials evaluating counseling vs wallet-sized referral cards and nurse management vs usual care during pregnancy showed improved outcomes in both the intervention and control groups, with no statistically significant difference between them.
Question 4: What are the adverse effects of screening for IPV and interventions to reduce harm?
There are few—if any—adverse effects, according to 3 RCTs and several descriptive studies. The RCTs found no adverse effects of screening or IPV interventions. Descriptive studies showed low levels of harm among a wide range of study populations and a variety of methods. However, some women experienced loss of privacy, emotional distress, and concerns about further abuse.
WHAT’S NEW: B recommendation is finalized
Given the relative safety of screening, the potential benefits of interventions for women who have positive screens, and the availability of accurate screening instruments, the USPSTF disseminated a draft recommendation that health care providers screen all women between 14 and 46 years old for IPV.At presstime in late January, the recommendation was finalized.8
CAVEATS: Universal screening questions remain
While the findings from this systematic review led the USPSTF to upgrade its recommendation for IPV screening from an I (insufficient evidence) to a B (moderate to substantial benefit of screening), additional high-quality studies are needed to definitively reveal the benefit of screening.
The validity of the large multicenter RCT that found no benefit from IPV screening was compromised by high dropout rates and, potentially, by the fact that women in the control group had access to materials that increased IPV awareness. Overall, the trials included in this systematic review ranged from fair to good quality and had relatively high and differential rates of loss to follow-up, enrollment of dissimilar groups, and concern for the Hawthorne effect (in which participants change their behavior simply as a result of being involved in a study).
What’s more, some trials used narrowly defined populations, which could limit applicability. And, while some earlier studies had found higher rates of IPV disclosure using self-administered instruments compared with face-to-face questioning, more research is needed to identify the optimal screening method.9
CHALLENGES TO IMPLEMENTATION: The right screen—and reliable follow-up
Five of the screening instruments used in studies included in this systematic review accurately identified women with past or present IPV. Three of these are suitable for use in primary care:
- HARK, a self-administered screen available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2034562/table/T1
- HITS, a face-to-face screen
- WAST, a self-administered screen (more information about these screens is available at http://www.cdc.gov/ncipc/pub-res/images/ipvandsvscreening.pdf).
After deciding which instrument to use, family physicians still must determine how to incorporate screening into a busy practice.
Finally, physicians should not screen for IPV until reliable procedures and resources for follow-up of patients who screen positive have been identified. Resources are readily available through local and national hotline numbers. The number of the National Domestic Violence Hotline is 800-799-SAFE.
Acknowledgement
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
