Current Evidence on Perinatal Home Visiting and Intimate Partner Violence

CNE

Continuing Nursing Education(CNE) Credit

A total of 2 contact hours may be earned

as CNEcredit for reading ‘‘Current Evidence

on Perinatal HomeVisiting and Intimate

Partner Violence,’’ and for completing an

online post-test and evalution.

AWHONN is accreditedas a provider ofcontinuing nursingeducation by theAmerican NursesCredentialing Center’sCommission onAccreditation.

AWHONNalso holds California and

Alabama BRN numbers: California CNE

provider #CEP580 and Alabama

#ABNP0058.

http://JournalsCNE.awhonn.org

Current Evidence on Perinatal HomeVisiting and Intimate Partner ViolencePhyllis W. Sharps, Jacquelyn Campbell, Marguerite L. Baty, Keisha S. Walker, and Megan H. Bair-Merritt

ABSTRACT

Objective: To describe current evidence on home visiting interventions for pregnant or postpartum women with

specific intimate partner violence assessment and content.

Data Sources: Online bibliographic databases including PubMed, CINAHL Plus, and Web of Science and a hand

search of bibliographies of relevant articles.

Study Selection: Original research and intervention studies were included that contained (a) a well-described pre-

natal and/or postpartum home visitation; (b) an assessment of perinatal intimate partner violence; and (c) quantitative

data describing health outcomes for the women and their infants.

Data Extraction: The search yielded 128 articles, and 8 relevant articles met all of the inclusion criteria. Non-

research, nonintervention, and international articles were excluded.

Data Synthesis: No perinatal home visiting interventions were designed to address intimate partner violence. Pro-

grams that screened for intimate partner violence found high rates, and the presence of intimate partner violence

limited the ability of the intervention to improve maternal and child outcomes.

Conclusions: Perinatal home visitation programs likely improve pregnancy and infant outcomes. Home visiting

interventions addressing intimate partner violence in nonperinatal population groups have been effective in minimizing

intimate partner violence and improving outcomes. This suggests that perinatal home visiting programs adding

specific intimate partner violence interventions may reduce intimate partner violence and improve maternal and infant

health. Continued rigorous research is needed.

JOGNN, 37, 480-491; 2008. DOI: 10.1111/j.1552-6909.2008.00267.x

Accepted January 2008

Intimate partner violence (IPV) continues to be a

major public health problem that a¡ects the

health and well-being of women and children. Preg-

nant women are not protected from IPV. Perinatal

home visiting (HV) interventions have been used

to reduce risks for poor pregnancy outcomes,

improve parenting skills and enhance infant devel-

opment, and they may have potential to reduce

the harms of IPV. The purpose of this article was to

conduct a comprehensive review of the literature

speci¢c to HV interventions for pregnant or postpar-

tum women, with a focus on IPV assessment and

content.

Violence Against WomenThe National Violence Against Women Survey docu-

ments that one in four women are raped and/or

physically assaulted by a current or former spouse,

cohabitating partner or date at some point in their

lifetime (Tjaden & Thoennes, 2000). Two recent

(2003-2005) surveys, one of 3,568 women in a large

HMO inWashington and Idaho and the other a pop-

ulation-based survey of 3,637 women from 12 U.S.

cities, found IPV prevalence of just under 8% for the

past year and 9.8% for the past 2 years, respectively

(Thompson et al., 2006; Walton-Moss, Manganello,

Frye, & Campbell, 2005). The abuse of women by in-

timate partners has been associated with traumatic

injuries, long term physical health consequences

(including headaches, sexually transmitted infec-

tions, and chronic backaches) and long term mental

health consequences (including depression, low

self-esteem, and posttraumatic stress disorder

[PTSD]) (Campbell, 2002; Humphreys & Campbell,

2004;Walton-Moss et al., 2005). Given the signi¢cant

magnitude and impact of IPV, preventing violence

against women has become a national health prior-

ity, as addressed in Healthy People 2010 (U.S.

Department of Health and Human Services, 2000;

DHHS 2001).

Pregnant women also experience IPV. Recent stud-

ies estimate that 3% to19% of women report being

CorrespondencePhyllis W. Sharps, PhD,RN, CNE, FAAN,Department of CommunityPublic Health Nursing,Johns Hopkins UniversitySchool of Nursing, 525 N.Wolfe Street—Room 433,Baltimore, MD [email protected]

Phyllis W. Sharps, PhD,RN, CNE, FAAN, is aprofessor and chair,Department of CommunityPublic Health Nursing,Johns Hopkins UniversitySchool of Nursing,Baltimore, MD.

Jacquelyn Campbell, PhD,RN, FAAN, is a professor,Anna D. Wolfe Chair, JohnsHopkins University Schoolof Nursing, Baltimore, MD.

(Continued)

Keywordshome visitationabusedomestic violencepregnancy

JOGNN I N F O C U S

480 & 2008 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses http://jognn.awhonn.org

i:/BWUS/jogn/267/[email protected]

abused during the childbearing yearçthat

is in the year before, during, or after a pregnancy

(Campbell, Garcia-Moreno, & Sharps, 2004).

Rates vary depending on how women are asked

(one-one interview, questionnaires, computer

assisted), the setting in which women are asked

(i.e., alone in a private location place, at triage in

an o⁄ce setting), at what point during the preg-

nancy they are asked, and which questions they

are asked.

Intimate partner violence during pregnancy has

been associated with poor health outcomes for

mother, fetus, and neonate. Poor maternal out-

comes include late entry into or no prenatal care,

poor maternal weight gain, and traumatic injuries

that may cause premature termination of the preg-

nancy. Similar to abused nonpregnant women,

abused pregnant women experience poor mental

health including low self-esteem, substance abuse

(including smoking), depression, and PTSD (Bull-

ock, Mears, Woodcocock, & Record, 2001; Martin,

Kilgallen, Dee, Dawson, & Campbell,1998). Intimate

partner violence has also been associated

with poor fetal and neonatal outcomes such as

preterm delivery and low birth weight (Murphy,

Schei, Myhr, & Du Mont, 2001). Abuse during preg-

nancy is also a risk factor for intimate partner

homicide of women, both during and after the

pregnancy (McFarlane, Campbell, Sharps, &

Watson, 2002).

Intimate partner violence continues to negatively

a¡ect children throughout childhood. Research in

the past 20 years documents that children exposed

to IPV are at risk for a host of poor social-emotional

and physical health outcomes including depres-

sion, anxiety, poor self-esteem, aggression, poor

peer relations, poor school performance, physical

health symptoms, under-immunization, and ado-

lescent risk behaviors (Bair-Merritt, Blackstone, &

Feudtner, 2006; Baldry, 2003; Holden, 2003; Fan-

tuzzo et al., 1991; Fredland, Han, & Campbell, in

press; Kernic et al., 2002; Polillo, 2003).

Despite the documented poor pregnancy and child

outcomes associated with IPV, there have

been few systematic or evidence-based interven-

tion strategies speci¢cally targeting the reduction

or prevention of IPV against pregnant women.

Commonly used strategies to address the health

issues related to perinatal IPV include early

case-¢nding to get women into prenatal care,

provision of nutritional support, and programs

to decrease substance use, including smoking

cessation.

Nurse HV: A Strategy forPreventing Perinatal IPVHome visiting historically has been an essential

component of public health/community health

nursing practice. Perinatal HV interventions have

been used to reduce risks for poor pregnancy out-

comes, improve parenting skills, and enhance

infant development (Gomby, 2000; Hahn et al.,

2003). The Olds nurse HV intervention (Nurse-Fam-

ily Partnership) has been recognized as the one

intervention with evidence for decreasing child mal-

treatment (Chalk, 2003; Chalk & King, 1998; Olds

et al., 2004b). Yet current economic slowdowns and

under funding of a variety of health initiatives and

interventions have forced many public health de-

partments to eliminate HV interventions.

The core content of most perinatal HV programs in-

cludes the following: (a) delivery of anticipatory

guidance; (b) implementation of a prespeci¢ed cur-

riculum to enhance parenting and/or child

development; (c) provision of social support and

practical assistance to caregivers ; and (d) referrals

to community resources. The prior education

and training of home visitors varies between

programs; some home visitors are paraprofession-

als, while others are nurses, social workers, or

health educators. Some literature suggests that

community/public health nurses are uniquely sui-

ted to be home visitors because of their advanced

training in maternal and infant health and parenting

and their ability to gain insight on family functioning

(Tandon, Parillo, Jenkins, & Duggan, 2005).

This comprehensive review of the literature speci¢c

to HV interventions for pregnant or postpartum wo-

men was designed with a focus on IPV assessment

and content. The overall goals of this work were

to benchmark current knowledge and establish a

foundation on which to develop future interventions

for abused pregnant and/or postpartum women.

The article concludes with a discussion of impor-

tant implications for evidence-based clinical

practice, and directions for future research and pol-

icy development for abused pregnant and/or

postpartum women and their infants.

MethodsTo examine the literature for this critique and

synthesis, a computerized literature search was

Intimate partner violence during pregnancy has beenassociated with poor health outcomes for mother, fetus,

and neonate.

JOGNN 2008; Vol. 37, Issue 4 481

Sharps P. W., Campbell J., Baty M. L., Walker, K. S., and Bair-Merritt, M. H. I N F O C U S

CNE


https://www.researchgate.net/publication/11333977_Academic_and_School_Health_Issues_Among_Children_Exposed_to_Maternal_Intimate_Partner_Abuse?el=1_x_8&enrichId=rgreq-036fd667-c2fa-44e1-af70-c413bc3f1894&enrichSource=Y292ZXJQYWdlOzIzMjIxMzg5O0FTOjEwMjk2Mzc1MDExMzI4OUAxNDAxNTU5ODc5NzY1

https://www.researchgate.net/publication/244821247_The_effects_of_domestic_violence_on_child_witnesses?el=1_x_8&enrichId=rgreq-036fd667-c2fa-44e1-af70-c413bc3f1894&enrichSource=Y292ZXJQYWdlOzIzMjIxMzg5O0FTOjEwMjk2Mzc1MDExMzI4OUAxNDAxNTU5ODc5NzY1

conducted in three databases: PubMed, CINAHL

Plus, and Web of Science. The limits were set

for original research articles based in the United

States that were published between 1997 and 2007

and written in the English language. Search terms

included ‘‘home visitation,’’ ‘‘abuse,’’ ‘‘pregnancy,’’

‘‘maternal health,’’ and ‘‘infant health.’’

Inclusion criteria for this critical review were estab-

lished a priori. The articles had to include (a) a

well-described prenatal and/or postpartum home

visitation intervention that utilized nurses, para-

professionals or lay health workers ; (b) an as-

sessment of perinatal (during pregnancy through

1 year after birth) IPV; and (c) quantitative data

describing health outcomes for the women and

their infants.

The PubMed, CINAHL Plus, and Web of Science

online database search produced a total of 439 ar-

ticles. The search was conducted ¢rst by using

individual, speci¢c keywords and then narrowed to

include keyword strings. This strategy was utilized

to prevent the exclusion of relevant articles.

An initial screening of article titles was used to

eliminate articles clearly not meeting study criteria

and to recognize overlap of articles between

search engines. Abstracts of all potentially relevant

articles were retrieved. A total of 128 potentially

relevant, nonrepeated abstracts were reviewed

to determine whether they met inclusion criteria.

Reasons for exclusion at the abstract level in-

cluded systematic reviews (11), international

studies, nonresearch commentary, or noninter-

vention studies. However, reference lists from all of

the 128 abstracts were reviewed for papers that

may not have been identi¢ed through the elec-

tronic search.

Articles with abstracts that indicated a good match

for this review, as well as those that did not mention

all of the inclusion criteria, were obtained and read

in their entirety to assess if inclusion was possible.

Additionally, articles that were written based on

the same study (i.e., Duggan’s Hawaii Healthy Start

evaluation) were read, and the most applicable

were selected for inclusion in this article.Those that

assessed family violence not inclusive of IPV (elder

abuse, child abuse), were published before 1997,

discussed HV not speci¢c to perinatal period, or re-

searched perinatal HV without addressing IPV were

excluded at this point. Table 1 details the number

of citations retrieved, the number of abstracts

reviewed, and the number of articles retained from

each database search.

Review of ResearchEight research reports were found that assessed

IPV and used home visitation during the perinatal

period (pregnancy through 1-year postpartum) to

improve maternal-infant health outcomes. These

studies are described in detail inTable 2. All studies

involved impoverished, high risk samples of women,

and sample sizes ranged from142 (Cerny & Inouye,

2001) to 1,139 women (Olds, Kitzman et al., 2004,

Olds, Robinson et al., 2004). Half of the studies as-

sessed IPV using the Child Abuse Potential (CAP)

or Con£ict Tactics Scale. Past year prevalence of

IPV ranged from14% to 52%. The research reports

included four intervention-based trials, one of

which was reported in several articles, and one

cross-sectional descriptive study. The following re-

view provides a summary of ¢ndings across

studies and comments about their applicability to

HV programs for perinatal IPV.

Co-Occurrence of Child Abuseand IPVA signi¢cant relationship between IPV and child

abuse has been well-established in the literature

(Appel & Holden, 1998; Edleson, 1999; Hazen,

Connelly, Kelleher, Landsverk, & Barth, 2004; Wind-

ham et al., 2004). One common goal of perinatal HV

programs is to decrease child maltreatment. Cerney

and Inouye (2001) recommended that HV nurses

provide education and support to families experi-

encing IPV to reduce the risk for child abuse. Early

intervention by home visitors that reduces IPV may

improve parenting attitudes and stabilize the home

environment thereby preventing abuse and neglect

and promoting positive childhood development

(Nair, Schuler, Black, Kettinger, & Harrington, 2003).

Intimate Partner Violence LimitingHV Program EffectsFailure to provide su⁄cient focus, time, and

resources on IPVmay limit the e¡ectiveness of peri-

natal HV programs in promoting positive child

Table 1: Search Process

Database

Searched

Citations

Retrieved

Original

Abstracts

Reviewed

Articles

Selected

PubMed 258 80 6

CINAHL Plus 109 36 2

Web of Science 72 12 0

Reference Lists N/A 8 0

Marguerite L. Baty, MSN,MPH, RN, is a doctoralstudent, Johns HopkinsUniversity School ofNursing, Baltimore, MD.

Keisha S. Walker, MSN,RN, is a community healthresearch nurse, JohnsHopkins University Schoolof Nursing, Baltimore, MD.

Megan H. Bair-Merritt,MD, MSCE, is an assistantprofessor of pediatrics,Division of GeneralPediatrics and AdolescentMedicine, Johns HopkinsUniversity School ofMedicine, Baltimore, MD.

Keisha S. Walker, MSN,RN reports receiving asalary as a Research Nursefrom the NINR fundedstudy, the Dove Program.All other authors report noconflict of interest orfinancial relationshiprelevant to this article.

482 JOGNN, 37, 480-491; 2008. DOI: 10.1111/j.1552-6909.2008.00267.x http://jognn.awhonn.org

I N F O C U S Home Visitation

CNE


Tab

le2:

IPV

an

dP

eri

nata

lH

om

eV

isit

ati

on

Art

icle

s

FirstAuthor

StudyDescription

Sample

Demographics

HomeVisitorTypeandTraining

InterventionParameters

ViolenceMeasuresandFindings

Eckenrode(2000)

15-yearfollow-upofOlds’

randomizedcontrolledtrial

(Elmira,N

Y)

Originalstudyconductedfrom

1978to1980

n5

324mother/childdyadsin

follow-up(from

400in

original

study)

Originalrecruitmentofpregnant

womenwithnopreviouslive

births,andeitherlessthan19,

unmarried,orlowSES

Originalstudy:47%

lessthan19

years

ofage62%

unmarried

61%

oflowSEShouseholds

Follow-up:81%

oforiginal

pairsinterviewed

Completedinterviewsdid

not

di¡erbytreatm

entgroup

Followuponthreearm

sofstudy.

Forgroups3and4,nurse

conductedhomevisiting.N

o

inform

ationprovidedonnurse

traininginthisarticle

Group1:sensory

and

developmentalscreeningof

childat1and2years;group2:

aboveandfreetransportation

forappointm

entsthroughage

2;group3:aboveplusnurse

homevisitsduringpregnancy;

group4:sameasgroup3with

nursevisitsto

child’ssecond

birthday.Nursepromoted

maternalfunctioning,child

care

andmaternallife-course

development.Visitsbiweekly

duringpregnancy,weeklyin

¢rst6weekspp,thenfewer

untilage2.Averageofnine

visitscompletedduring

pregnancyand23untilsecond

birthday

IPVmeasuredbyCTS

48%

ofmothers

reportedIPV

sincethebirth

ofindexchild,

meannumberofincidentswas

22.2

overthe15

years

Signi¢cantlylesschild

maltreatm

entwithmothers

experiencinglessthan28

fewerincidentsofIPVin15

years

Treatm

ente¡ectofintervention

decreasedsigni¢cantlyaslevel

ofIPVincreased(po.04-.001)

Cerny(2001)

Onegrouppre/posttest

interventionstudyin

Hawaii

amongmilitary

families

identi¢edasat-riskforchild

abuse

n5142(pregnantormothers

of

newborns)Allfrom

enlisted

military

families.Manyonfood

stampsandassistance,73%

married,65%

White,21%

AfricanAmerican

Nurses(nospeci¢cmentionof

quali¢cations)

Nursesvisited2�/m

onth

until

baby1yearold

Educationprovidedregarding

parentingissues,bonding,

breastfeeding,discipline.

Interventionfocusedon

increasingmother’sself-

esteem,knowledgeand

con¢dencein

caringforbaby

History

ofspouseabuse

measuredforcorrelationto

ChildAbusePotential(CAP).

Spouseabusesigni¢cantly

correlatedwithchildabuse

(po.04)amongthosewith

higherCAPscores

CAPscoresshoweddecline

followingintervention

Olds(2002)

Randomizedcontrolledtrialin

Denver,CO

n5

735(255

5control;

245

5paraprofessionals;

235

5nurse)Pregnantwomen

withnopriorlivebirths,eligible

forMedicaid

Allgroupssimilaratbaselin

ein

age,race/ethnicity,alcohol/

druguse,andmaritalstatus

Threestudyarm

s(control,

paraprofessionalhomevisits,

nursehomevisits).Alltrainedin

homevisitingprotocols

Nurses:6.5prenatalhomevisits;

21visitsbetw

eenbirth

and

child’ssecondbirthday

Paraprofessionals:6.3

prenatal

homevisits;16visitsbetw

een

birth

andchild’ssecond

birthday

IPVmeasuredwithCon£ict

TacticsScale(CTS)

Wholegroupatbaseline:16%

reportedexperiencing

domesticviolencein

last6

monthsin

controlandnurse

groups;18%

in

paraprofessionalgroup



CNE


Nair(2003)

Studywaspartoflarger

longitudinalRCTofhome-

basedinterventionfor

substance-abusingwomen

withinfants

n5161substance-abusing

mothers

Eligibleifwomanorinfanthad

positivetoxicologyscreenat

birth.Postnatalhomevisiting

only

Sample‘‘predominantlyAfrican

American’’

Layvisitors

TrainingbasedontheHawaii

EarlyLearningProgram

(HELP)andInfantHealthand

Developmentprogram

Weeklyhomevisitsfrom

0to

6

months,biweekly

visits6-24

months

InterventionbasedonInfant

HealthandDevelopment

Program

augmentedwith

inform

ationspeci¢cto

substanceuse/abuse

Goalwasto

increasematernal

empowerm

ent

IPVde¢nedbysinglequestion

overthepast18

months:‘‘Sincewe

sawyoulast,have

youbeena

victim

ofdomesticviolence?’’,

scored0(nonesincestudyentry),

1(ifreportedbeingabusedat

6,12,or18monthsvisit)

Usedasfactorto

quantify

mother’senvironmentalriskç

cumulativeriskindex

Nosigni¢cantdi¡erence

betw

eeninterventionand

controlgroups

Duggan(2004)

Randomizedcontrolledtrial,

threesitesin

HawaiiFamilies

enrolledprenatallyoratbirth

of

child,randomizedto

interventionorcontrol.Data

from

follow-upinterviews,89%

oftotal.Lostto

follow-upnot

signi¢cantlydi¡erentfrom

thoseremaining

n5

643families(373HSP;270

control)

Groupscomparablein

age

(mean23.7,23.3years,

respectively),4

60%

household

incomebelow

povertylevel,indexchild

¢rstborn

innearlyhalfof

families

Para-professionalstrainedwith5

weekscore

trainingincluding

childdevelopment,child

abuse,problem

solvingand

domesticviolence

HealthyStartProgram

model

focusedonimprovingfamily

functioning,therebypreventing

childabuseandpromoting

childhealthanddevelopment

Homevisitingfor3-5

years

(Level1

weekly

visits;Level2

biweekly,Level3monthly,Level

4quarterly)

IPVmeasuredwithCTSControl

groupmothers

reportedmore

IPVatbaselin

ethan

intervention(52%

comparedto

43%

,po.02)

Homevisitationdid

notimprove

motherorchildoutcomes

includingnodi¡erencesin

childmaltreatm

ent

Olds(2004)

Randomizedcontrolledtrial

FollowuponpreviousColorado

study(O

lds,2002)

n5

635(220

5control;

211

5para;204

5nurse)

Twoyearfollow-upaftercloseof

study(2002,seeabove)

Followuponthreestudyarm

s

(control,para-professional

homevisits,andnursehome

visits).Alltrainedinhome

visitingprotocols

Seeabove

IPVmeasuredthroughCTS.O

R

forIPV(past6monthsand

sincechildage2)control

versuspara-professional

nonsigni¢cant.ORforpast6

monthsIPVcontrolversus

nurse.47(p

5.05);OR.60for

IPVsinceage2(p

5.09)

Olds(2004)

Randomizedcontrolledtrial

Followuponprevious

Memphis,TNstudyin1990-

1991

n51,139(1:166;2:515;3:230;4:

228)92%

Black;85%

below

povertylevel;98%

unmarried;

64%

lessthan18years

ofage

atenrollment;all¢rsttime

mothers

Fourarm

s(twowithnursehome

visitors;nopara-professionals)

Group1:transportationto

prenatalvisits,nopostpartum

visits;group2:sameas

above

1infantassessments;

group3:sameas¢rst

group

1intensivehomevisiting

prenatally,twopostpartum

visits;group4:sameasgroup

31nurseHVthroughchild’s

secondbirthday

Samethreegoalsforhome

visiting:improveoutcomesof

pregnancy,improvehealthof

childrenthroughpromoting

competentcare

byparents,

andenhanceparents’life

coursedevelopmentthrough

pregnancyplanning,¢nding

work,andcompleting

education

Focusedonself-e⁄cacyand

resourceuse

Outcomevariable

Measurementnotspeci¢ed

Includedexperienceof

domesticviolence,birth

toage

6y;noe¡ectonIPV(p

5.87)

Tab

le2:

Co

nti

nu

ed

FirstAuthor

StudyDescription

Sample

Demographics






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Tandon(2005)

Cross-sectionalstudyofmothers

andhomevisitors

currently

engagedinhomevisitation

program

n5189(m

others)n

545(home

visitors)

Recruitedpregnantwomenor

womenwithchildunder6

months

Familieseligibleifparticipatedfor

atleast3months,hadthebest

relationship

withprogram

Trainingandhomevisitortype

variedbyhomevisitorprogram:

HealthyStartmodel,Healthy

FamiliesAmericamodeland

communitydevelopedmodel

allusedpara-professionals

Locallydevelopedmodelused

nursingstudents

Homevisitors

receivedtraining

onprogram

goals,services

andoperatingprocedures;

history

ofhomevisiting;issues

ofcon¢dentiality;childabuse/

neglectreportingrequirements

Fourhomevisitingprogram

modelsassessedforwomen’s

needforIPVresourcesand

homevisitors’abilityto

identify

anddiscussIPVwithmothers

Homevisitingprovidedfor1-3

years;newfamiliesreceive

visitsatleastevery

2weeks,

decreasingasmilestonesare

reached

NeedforIPVservicesmeasured

bya⁄rm

ativeanswerto

oneor

both

items:‘‘Are

you

experiencingaphysical

domesticabuseproblem

with

yourcurrentpartner?’’or‘‘Are

younowexperiencingaverbal

oremotionalabuseproblem

withyourcurrentpartner?’’Also

askedaboutreceipt,wantor

needforDVservicessince

joiningtheprogram

Of26mothers

positiveforIPV

serviceneed(14%

),only¢ve

(19%

)were

receivingservices,

andonlyoneofthosereceiving

serviceshadbeenreferred

there

byhomevisitor

Homevisitors

whofeltmore

adequatelytrainedin

aspects

ofIPVreportedmore

e¡ective

addressingIPV(po.05)

Note.H

V5

homevisiting;IPV

5intimate

partnerviolence.

Tab

le2:

Co

nti

nu

ed

FirstAuthor

StudyDescription

Sample

Demographics






CNE


development. A nationwide nurse home visitation

program reported that their program was not as

e¡ective in decreasing child abuse and neglect in

households with IPV (Olds, 2002). In another analy-

sis of the same program, Eckenrode found that in

families with more than 28 episodes of IPV, the HV

intervention was ine¡ective at reducing child mal-

treatment (Eckenrode et al., 2000). This highlights

the importance of screening and intervening for

IPV, because the signs may not be obvious. If IPV is

left unaddressed, the associated risks can signi¢-

cantly impact the greater family environment.

Response: Screening and ReferralDespite the need for a focus on IPV, none of the re-

viewed HV programs included speci¢c, targeted IPV

content delivered as a part of the HV intervention

program. Instead, IPV was addressed by screening

and/or identifying the problem when signs were

clear (e.g., obvious bruising, spontaneous dis-

closure by clients) and making outside referrals.

Comfort in screening and making referrals for IPV,

however, varied among home visitors, with many

citing barriers such as limited IPV training.

For example, Duggan et al. (2004a, 2004b, 2004c)

found that home visitors in Hawaii Healthy Start

rated their competence in addressing IPV as low.

More importantly, the paraprofessional home visi-

tors in this study were not able to make appropriate

referrals to community resources when necessary.

In addition,Tandon et al. (2005) found that parapro-

fessional home visitors demonstrated limited ability

to communicate and respond to issues concerning

IPV. These ¢ndings are consistent with prior litera-

ture, mostly in acute and clinical health care

settings, that has identi¢ed many barriers to routine

screening for IPV (Fried, Aschengraue, Cabral, &

Amaro, 2006; Yonaka, Yoder, Darro, & Sherck,

2007). These barriers include lack of education

and training, con¢dentiality issues, time restric-

tions, personal experience with IPV, inadequate

resources, and selective screening of patients.

Nurses making home visits likely face the same bar-

riers to IPV screening and referrals as other nurses

and other health professionals. Hence, while nurse

home visitors’ ability to be e¡ective in improving

maternal and infant outcomes using the Nurse

Family Partnership model has been clearly docu-

mented (Olds, Kitzman et al., 2004; Olds et al.,

2002), the e¡ectiveness of nurse home visitors in

screening and addressing IPV has not been dem-

onstrated. In all of the studies reviewed, lack of

education and training were identi¢ed as barriers

for all home visitors, including nurses, who screen

for and refer patients experiencing IPV. There is a

need for future studies that examine what type of

training (i.e., nursing, paraprofessional) is best

suited to provide HV related to IPV.

Summary of Evidence to DateOne strength of the studies reviewed is that the

underlying study methodologies were solid, with

several evaluating data from four randomized control

trials, and although they only reported cross sec-

tional data most studies used standardized

measures of IPV, either CTS or the CAP, both of

which have good reported psychometric properties

and have been tested for use in diverse populations.

The studies reviewed had several limitations. The

majority of the studies reported cross-sectional

data only, which provides little knowledge about

the pattern of IPV during prenatal and postpartum

period. Across all studies, families included in the

samples were low income and Medicaid eligible,

which limits generalizing ¢ndings to families of other

socio-economic backgrounds. However, most

home visitation programs are limited to ‘‘at risk’’

families, usually of low income. Studies also used

di¡erent types of home visitors with di¡ering edu-

cational backgrounds and preparation for the HV

roles. Most studies did not report documentation of

home visitors’ adherence to study protocols or

monitoring ¢delity. Thus, it is di⁄cult to determine

how much of the HV intervention protocol families

received and how this in£uenced IPVoutcomes.

Despite the limitations cited, we identi¢ed several

important trends when considering the ¢ndings

from these studies. Home visiting programs in-

cluded assessment and referrals for IPV, but they

did not have speci¢c curricula designed for the

home visitor to provide direct intervention. Home

visitors often felt inadequately trained to deal with

IPV. In some programs, the presence of IPV limited

the ability of the intervention to improve maternal

and child outcomes (Eckenrode et al., 2000).

Additionally, these studies suggest that, given their

advanced health care education and comprehen-

sive assessment skills, nurses might be better

positioned than paraprofessionals to provide com-

prehensive HV services, especially in terms of child

abuse prevention (Duggan, McFarlane, Fuddy,

Burrell, & Higman, 2004d; Olds, 2002; Olds, Kitz-

man et al., 2004, Olds, Robinson et al., 2004).

However, it remains unclear whether or not nurses

are more e¡ective than paraprofessionals in con-

ducting IPV-related HV intervention.



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DiscussionIntimate partner violence is perhaps the proverbial

‘‘elephant in the room.’’ Violence against women in

the perinatal period is common and leads to nega-

tive health outcomes for women and infants. Failure

to recognize and directly and e¡ectively address

this issue may prevent perinatal HV programs from

achieving their desired outcomes.

Prior work documents that HV canbe e¡ective in im-

proving the health and well-being of nonpregnant

abused women. Speci¢cally, in a longitudinal exper-

imental study, Sullivan and Bybee (1999) used para-

professional advocates to deliver a 10 week home

visitation intervention after shelter stay. Researchers

found that women receiving advocacy HV (n 5135)

experienced less physical violence, sought more

community resources and had improved emotional

health and support than women in the control group

(n 5130) (Sullivan & Bybee,1999).

Similarly, a pilot project, Passport to Health, tested

the feasibility and e⁄cacy of a community health

nursing home visiting intervention (CHNHVI) for

abused women leaving a domestic violence shelter.

The goals of the program were to reduce health dis-

parities by increasing (a) access to health care; (b)

health promoting and safety behaviors ; and () par-

enting skills of women and children survivors of IPV.

Women and children received up to 14 weekly visits

over a 6-month postshelter stay. A total of 14 women

were recruited,10 women completed the intervention,

and 9 women had su⁄cient data to conduct ana-

lyses. Among those women, the mean age of the

women was 29 years, 7 were African American, 1

was Latina, and 1 was White. There were no signi¢-

cant di¡erences between those who completed and

those who did not complete the study. No enrolled

womanwaspregnant, but two of the enrolled women

had infants whowere less than 6 months old at base-

line. The postshelter CHNHVI included health

education for women’s and children’s health and

parenting, strategies for implementing safety plans

and reducing IPV, and coaching and/or referrals for

accessinghealth care.There were several signi¢cant

changes from baseline to the 6-month follow-up.

Speci¢cally, using the Abuse Assessment Screen,

the women reported decreased IPV (p 5 .003); de-

creased emotional abuse based on the Women’s

Experiences with Battering (p 5 o.001); improved

health measured with the Miller Abuse Physical

Symptoms and Injury Scale (p 5 .012); decreased

danger in intimate partner relationships using the

Danger Assessment (p 5 .014); and increased self-

esteem using the Rosenberg Self-Esteem Scale

(p 5 .012). Both Sullivan’s work and the preliminary

work of Passport to Health suggest that HV with a

speci¢c IPV curriculum is feasible and e¡ective with

abused women, and warrants further testing with

abused women in the perinatal period (Sharps,

Price, & Wynn, 2004; Sullivan & Bybee,1999).

RecommendationsImplications for PracticeHealth care providers have frequent contact with

women during prenatal, postpartum, and well-child

visits. Additionally, health care providers often have

long-standing relationships with their patients that

a¡ord the trust and partnership needed to discuss

sensitive psychosocial issues such as IPV.Given the

high rates of IPV in the perinatal period and the as-

sociated negative health outcomes, health care

providers should routinely screen women for IPV;

without such screening, few IPV cases are likely to

be detected and women cannot be appropriately

referred to resources such as home visitation.

Screening should be done sensitively and privately,

with protocols detailing best-practice responses to

help women disclosing abuse. Additionally, it is im-

portant for health providers to serve as advocates

for abused women, supporting them in their deci-

sion making and providing necessary resources

and referrals. Communication with local domestic

violence agencies can facilitate the development of

plans to meet the needs of these women. Network-

ing with local domestic violence agencies may also

provide opportunities for training health care pro-

viders about issues related to IPV screening and

intervention. Intensive perinatal home visitation with

direct IPV intervention for abused women, if avail-

able, may o¡er additional support and bene¢t.

Implications for ResearchThis review revealed the relative dearth of perinatal

HV programs that screen and provide interventions

for IPV. Rigorously designed randomized controlled

trials are needed to determine the risks and bene-

¢ts of adding speci¢c IPV curricula to perinatal

home visitation programs. These trials should

consider multiple endpoints including pregnancy

outcome, maternal physical and mental health,

infant growth and development, and child maltreat-

ment. Additionally, these studies ideally should

follow maternal-child dyads for several years to de-

termine if the impact of the home visitation program

is sustained over time.

Prior work documents that home visiting can be effectivein improving the health and well-being of non-pregnant

abused women.



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The Domestic Violence Enhanced Home Visitation

(DOVE), funded by National Institute of Nursing Re-

search, represents one promising randomized

control trial evaluating the e⁄cacy of a community

health nursing home visitation program for at risk,

pregnant women who have experienced IPV.

Women from both urban and rural settings are

recruited through health departments. For women

randomized to the intervention group, DOVE uses

a brochure-based curriculum to increase women’s

knowledge of abuse, provide them with options,

and empower them to make decisions and adopt

behaviors that will prevent and reduce further IPV.

Future research also should pursue the question of

how to improve cost-e¡ectiveness of HV services

including direct intervention for IPV. While nurses

have been shown to deliver e¡ective HV, poten-

tially related to their expertise and holistic

approaches to health care, both cost and repro-

ducibility must be considered. A study that directly

compares the ¢nancial costs, home visitor training

needs, and participant outcomes for HV interven-

tions by nurses versus para-professionals would

be useful.

Implications for PolicyFuture research must further examine how to de-

liver perinatal home-based interventions most

e¡ectively, including cost-e⁄ciency, with a spe-

ci¢c focus on how to best intervene in families

with IPV. In order to continue to study this promising

intervention strategy, however, there must be con-

tinued ¢nancial support of rigorously designed

trials of perinatal HV programs that include

speci¢c interventions for IPV prevention and inter-

vention.

Meanwhile, the data reviewed here clearly justify

addressing IPV in home visitation programs. All

home visitors need to be trained in the dynamics of

IPV, how to assess and how to intervene, as is now

being done in Healthy Start Programs (Rivera,

2006). At the least, home visitors should routinely

assess women for IPV at entry into the program,

one other time during the prenatal period (when

trust has been established) and at postpartum,

when abuse is known to restart (e.g., Martin, Mack-

ie, Kupper, Buescher, & Moracco, 2001; Saltzman,

Johnson, Gilbert, & Goodwin, 2003). Appropriate

community referrals to domestic violence shelters,

advocacy programs and the criminal justice system

if desired should be discussed with abused women,

and the home visitor should provide assistance in

making those referrals. As with other health prob-

lems, home visitors need to periodically assess

what is happening with the violence in follow-up

visits. These basic procedures with appropriate

training should be part of all home visitation

programs.

ConclusionsPerinatal IPV is a signi¢cant public health problem,

which a¡ects pregnancy outcomes as well as the

health of mothers and infants. Nurses often have

long-standing relationships with their patients and

are therefore ideally suited to screen women for

IPV. Providing abused women with support and, as

appropriate, with referrals to community agencies,

empowers women and may improve both their and

their infants’ health.

Perinatal home visitation programs likely improve

pregnancy and infant outcomes. Although we were

unable to ¢nd any perinatal HV programs that had

speci¢c IPV intervention content, there have been

at least two nonperinatal HV studies that have spe-

ci¢c interventions to address IPV. These studies

provided preliminary evidence that nurse HV pro-

grams may be able to appropriately adapt such

interventions to address and reduce perinatal IPV.

Practicing nurses should investigate perinatal

home visitation programs in their communities as

one option to support at-risk women.

AcknowledgmentsPassport to Health: Reducing Violence Related

Health Disparities was funded in part by the JHU-

SON Center for Health Disparities Research, NINR

P20-NR008375-01.

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Continuing Nurisng Education

Learning Objectives:

After reading this article the learner will be able to

1. Describe the health consequences for women asso-

ciated with intimate partner violence (IPV).

2. Discuss the adverse perinatal health outcomes asso-

ciated with IPV.

3. Describe the current evidence on home visiting inter-

ventions for pregnant or postpartum women who

have been exposed to IPV.

4. Identify best practices for perinatal home visiting

which may reduce IPV and improve maternal and in-

fant outcomes.

Post-Test Questions:

1. IPV is a major public health problem that

a. a¡ects the health and well being of children

b. a¡ects the health and well being of mothers

c. a¡ects the health and well-being of mothers

and children

2. Survey data documents that the number of

women raped or physically assaulted by a cur-

rent or former intimate partners is

a. 1 in 4 women

b. 1 in 10 women

c. 20% of all women

3. IPV against women is not associated with

a. decreased cognitive functioning

b. long term physical health problems

c. mental health problems

4. Recent research data indicates that

a. about 3-19% of pregnant women report IPV

b. less than1% of pregnant women report IPV

c. pregnancy protects women from IPV

5. When reporting IPV, pregnant women are not

in£uenced by

a. how they are asked

b. when they are asked

c. who asks them

6. IPV against pregnant women is not associated

with

a. low birth weight

b. multiple gestation

c. preterm delivery

7. The children of mothers exposed to IPV during

pregnancy and infancy experience negative

e¡ects into childhood that include

a. delayed growth

b. poor athletic skills

c. poor peer relations

8. The core content of perinatal home visit pro-

grams should not include

a. delivery of anticipatory guidance

b. implementation of problem solving curricu-

lums

c. provision of social support to parents/care-

givers

9. Several studies suggest that community/public

health nurses are uniquely quali¢ed to for peri-

natal home visiting because

a. these nurses have advanced training in

family therapy

b. these nurses have advanced training in

therapeutic interventions

c. these nurses have the ability to assess family

functioning

10. One common goal of all perinatal home visit

programs is to

a. decrease child maltreatment

b. decrease contraceptive failures

c. decrease family con£icts

11. Home visit programs with speci¢c IPV content

that targeted abused non-pregnant women

have demonstrated promising results be-

cause signi¢cantly more women reported

a. leaving violent intimate relationships

b. less physical violence

c. less traumatic injuries

12. Current research ¢ndings related to perinatal

home visiting for IPV identi¢ed the following

weakness:

a. A variety of types of home visitors were studied

b. Most studies were longitudinal

c. Studies included families from all SES levels



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13. Recommendations for best practices for peri-

natal home visit programs aimed at targeting

IPV include

a. interactive IPV curriculum

b. routine screening for IPV

c. speci¢c time limits for IPV

14. Recommended guidelines for IPV screening

for home visit program that target pregnant

women are

a. screening at entry into the home visit program

b. screening at prenatal and postpartum

visits

c. screening for half of the scheduled visits

15. An important consideration for future research

related to perinatal home visit programs is

a. rigorously designed descriptive longitudinal

studies

b. rigorously designed randomized controlled

trials

c. rigorously designed short term studies



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Current Evidence on Perinatal Home Visiting and Intimate Partner Violence

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