Pregnant trauma patients with certain injury patterns—including multiple injuries, injuries to the head, face, neck, and scalp, and multiple contusions—should be screened for intimate partner violence (IPV), according to study results published in the Journal of the American College of Surgeons (JACS).

The study, "Intimate Partner Violence in Pregnancy: A Nationwide Analysis of Injury Patterns and Risk Factors," defines specific risk factors for IPV in pregnant patients—and provides key recommendations on which subset of pregnant patients should be screened for IPV.

Lead author Paul Thomas Albini, MD, FACS, an acute care surgeon at Riverside University Health System, Moreno Valley, California, notes that this study was born out of a concern from the staff at his hospital who noticed an uptick in pregnant trauma patients affected by IPV in recent years.

"To the best of my knowledge, there has not been an analysis to show specific risk factors for intimate partner violence in a defined population," said Dr. Albini, who is also an assistant professor of surgery at Loma Linda University and the University of California, Riverside. "We wanted to study intimate partner violence in pregnant patients as we know that they are particularly vulnerable, and their outcomes are generally poor."

IPV—which includes forms of physical, emotional, sexual, or psychological abuse—is a significant global health problem, affecting about 1 in 4 women and 1 in 10 men in their lifetime. Pregnant patients are especially vulnerable. About 3% to 9% of women experience abuse during pregnancy, and trauma is the leading cause of non-obstetric maternal death, affecting approximately 8% of pregnancies.

Public health experts and the American College of Surgeons (ACS) IPV Task Force have raised the alarm that IPV may be severely underreported, and may have worsened during the COVID-19 pandemic when lockdowns prevented many from seeking help.

Current methods and tools for IPV screening vary per hospital system. Guidelines for trauma center recognition of IPV from the ACS Trauma Quality Programs (TQP) recommend universal IPV screening for trauma patients of all ages seeking health care, noting that IPV is linked to increased self-reported mental illness, substance abuse, and recurrent injuries.

In pregnant patients who experience IPV, fetal outcomes can also be impacted, leading to premature birth and low birth weight. Surgeons can play an important role in recognizing IPV in patients by incorporating screening tolls into healthcare assessment protocols.

Study details

Using the Nationwide Emergency Department Sample (NEDS) database—part of the Healthcare Cost and Utilization Project (HCUP)—the researchers identified pregnant adult women patients (18-44 years old) who visited emergency room (ER) departments with traumatic injuries between 2010-2014. Based on injury code, the authors first compared pregnant IPV patients with pregnant trauma (non-IPV) patients and completed a secondary analysis comparing pregnant IPV patients with non-pregnant IPV patients.

In both comparisons, the researchers noted demographics, injury mechanisms, and National Trauma Data Standard injury diagnoses of the patients. They then used statistical analyses to identify risk factors and the outcomes of pregnant IPV patients. In total, they analyzed data from 556 pregnant IPV patients, 73,970 non-IPV pregnant trauma patients, and 56,543 non-pregnant IPV patients.

Key findings

• Risk factors in pregnant trauma patients that may point toward IPV include multiple injuries, head injuries, face, neck, and scalp injuries, as well as contusions and abrasions.
• Pregnant IPV patients were more likely to experience abdominal injuries, firearm violence, and abrasions/friction burns compared with non-pregnant IPV patients.
• Due to the vulnerability of both the mother and fetus, pregnant IPV patients may benefit from increased monitoring during their hospital stay.
• Most pregnant and non-pregnant IPV patients were treated and released from the ER, with no significant difference in mortality and hospital admissions between the two groups.
• Pregnant women with multiple injuries and those who had experienced firearm violence were more likely to be admitted to the hospital.
• Pregnant IPV patients were younger, and more often had Medicaid insurance or self-pay coverage than private/HMO insurance, though income distribution was not significantly different between the groups.
• The authors concluded that trauma systems should consider improving screening methods and offer counseling and prevention measures in the ER, where most patient care will occur before discharge.

Helping stop the cycle of violence

The study was retrospective and included a relatively small sample size of pregnant women with reported IPV, so it may not capture granular data on suspected IPV cases and other larger demographic data on IPV patterns, Dr. Albini noted. But the study points to several important risk factors to recognize patterns of IPV injury more closely.

"I think we have identified certain risk factors that should prompt screening for intimate partner violence. Using these risk factors to guide screening can happen anywhere, not just at our institution," he said. "I think that would be very helpful and may address an underlying problem for a proportion of patients."

He also hopes the study illuminates more of the complexities of screening for IPV—and many of the unanswered questions that still need to be investigated. There are validated tools for IPV screening, but many hospital staff may lack guidance on who to screen, and how to provide appropriate counseling or follow-up care.

"This study was eye-opening in so many ways on the more research that needs to be done," Dr. Albini said. "We need to prevent the cycle of violence from happening again."