Looking at Intimate Partner Violence (IPV) and Perinatal Depression (PD)

1. Looking at Intimate Partner Violence (IPV) and Perinatal Depression (PD) HRSA Social Solutions International March 6, 2012 2pm-3pm EST

2. Webinar Speakers and Guests • Moderator: Cara Finley, MPH Social Solutions International, Inc. • Keisher Highsmith, DrPHHRSA, Division of Healthy Start and Perinatal Services • Diana Cheng, MDMedical Director of Women’s Health, Maryland Department of Health and Mental Hygiene • Ifeyinwa Udo, DrPH (c), CPHMorgan State University & Johns Hopkins School of Nursing

3. Objectives • Discuss the intersection and effects of Intimate Partner Violence (IPV) and Perinatal Depression (PD) • Discuss IPV/PD screening • Introduce the HRSA IPV/PD Toolkit for Healthy Start Programs

4. Intersection between Perinatal Depression and Intimate Partner ViolenceMarch 6, 2012Diana Cheng, M.D.Women’s HealthMaryland Department of Health and Mental Hygiene

5. Definitions Perinatal Depression (PD) Intimate Partner Violence (IPV) Pattern of assaultive or coercive behaviors perpetrated by a current or former intimate partner Physical Emotional Sexual • Depression occurring • During pregnancy • Within the first postpartum year

6. Overlap of Types of IPV Sexual Physical Emotional

7. Prevalence of Rape, Physical Violence, and/or Stalking by an Intimate Partner, U.S. Source: National Intimate Partner and Sexual Violence Survey, 2011

8. Ipv prevalence • One out of every three American women will experience IPV in her lifetime. Source: National Intimate Partner and Sexual Violence Survey, 2011 • IPV accounts for a significant cause of injuries and emergency room visits among women. Source: US DOJ 2005 • IPV is a leading cause of female homicides. • Homicide is the leading cause of death during pregnancy and postpartum in Maryland Source: Cheng, 2010

9. Depression and IPV Across the Female Life course Highest prevalence=reproductive ages What is the significance of pregnancy/postpartum? Birth Death Menopause Menarche

10. PD and IPV: Under-recognized PD IPV Under-recognized Non-”medical” Isn’t this normal? Under-diagnosed Poor screening/counseling Stigma Under-treated Effect on family Access to care • Under-recognized • Non-”medical” • Isn’t this normal? • Under-diagnosed • Poor screening/counseling • Stigma • Under-treated • Effects on fetus/infant • Access to care

11. PD and IPV: Prevalence PD Perinatal IPV Prevalence varies 1-20% during pregnancy Depends on definition and population studied 4-8% in most studies Confidence intervals are high High degree of uncertainty Source: JAMA 1996 • Prevalence varies • 9-11% during pregnancy • 7-13% 1st postpartum year • As high as 20% in some studies • Confidence intervals are high • High degree of uncertainty Source: Agency for Health Care Research and Quality (AHRQ), 2005

12. Factors Associated with PD and IPV,Maryland PRAMS Data PD Perinatal IPV Previous history of IPV Maternal age <25 Unhappy about pregnancy Multiple stressors Relationship, financial, traumatic Cigarette smoking Binge drinking History of depression • Previous history of PD • Maternal age <25 • Unhappy about pregnancy • Multiple stressors • Relationship, financial, traumatic • Cigarette smoking • Binge drinking • History of IPV Source: Maryland PRAMS

13. PD and IPV: Who is high risk??? Depression IPV Occurs among all demographic groups socio-economic culture race religion sexual orientation education gender Female >>male • Occurs among all demographic groups • socio-economic • culture • race • religion • sexual orientation • education • gender • Female >>male

14. PD and IPV: Universal assessment PD IPV Majority of women do not mind being asked about IPV 90% comfortable with screening Source: Zeitler 2005 Majority of women are not asked about IPV 10% reported screening by ob/gyns Source: Rodriguez 1999 • Majority of women do not mind being asked about PD • 80% comfortable with screening Source: Buist 2006 • Majority of women are not asked about PD • <50% are screened • 22% used validated tool Source: Seehusen2005

15. Postpartum Depression: Impact of Abuse during Pregnancy Maryland PRAMS, 2004-2008 • Depression was reported by women who were: • Physically abused (39%) • Threatened or made to feel unsafe (35%) • Felt daily activities were controlled (36%) • Frightened for safety of family (33%) • Forced to take part in sexual activity (31%) • The prevalence of postpartum depression by IPV during pregnancy was 34.6% compared to 11.9% without IPV.

16. Postpartum depression and Unhealthy Factors, Maryland PRAMS 2004-2008 • Postpartum depression was reported by women • 39% of women who were physically abused during pregnancy • 37% of women who were binge drinking during pregnancy

17. Postpartum Depression (PPD) and stressors • PPD was reported by 39% of women who were physically abused during the year before delivery.

18. Perinatal Physical Abuse and unhealthy factors • Physical abuse before or during pregnancy was reported by: • 17% of women with PPD • 17% of women who smoked during pregnancy • 16% of women with no prenatal care

19. Perinatal Physical abuse and stressors • Physical abuse before or during pregnancy was reported by: • 30% of women who were divorced or separated in the year before delivery • 29% of women whose partners did not want the pregnancy • 20% of women whose partners lost their jobs or were in jail • 16% of women who were homeless

20. Overlap of PD and perinatal IPV PD IPV

21. Affordable Care Act • As of 9/23/10, requires health insurers, including Medicare, to offer certain preventive health services free of co-pays for new health plans • Depression screening, alcohol abuse screening/counseling, tobacco cessation, STI prevention screening/counseling for those at high risk • Institute of Medicine Clinical Preventive Services for Women, 7/2011, recommendation for women and adolescent girls • Screening/counseling for interpersonal/domestic violence in a culturally sensitive and supportive manner • DHHS Secretary Sibelius • Starting in first plan year after 8/2012 [for many plans, starting 1/2013], complete insurance coverage without copays • IPV/DV, contraception methods, STI counseling, well woman visits

22. ACOG Committee Opinion 2012 “Number 518, February 2012 Committee on Health Care for Underserved Women This information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Intimate Partner Violence Assess all women at 1st prenatal visit, each trimester and postpartum.”

23. Intersection between PD and IPV SUMMARY • Under-recognized, under-diagnosed, and undertreated • Prevalence • All demographic groups affected • Age <25 • Wide confidence intervals in different studies, 5-20% • Associated with stressors, smoking, alcohol use, unwanted pregnancy • Co-morbidity of PD and IPV • Preventable • Women don’t mind being screened • Resources [treatment, services] available to help women • Impact on maternal and child health can therefore be prevented

24. Intimate Partner Violence (IPV) & Perinatal Depression: Research Findings Ifeyinwa Udo DrPH(c), CPH Morgan State University School of Community Health/ Johns Hopkins University School of Nursing

25. Definition of IPV • Physical, sexual or psychological harm • By current or former partner or spouse • Younger women, separated or divorced, less educated, perinatal period are at increased risk

26. Perinatal Depression (PD) • Major and minor episodes during pregnancy(antenatal) • And /or within 1st 12 months after delivery(postpartum) • Prevalence: 20% (antenatal), 12-16% (postnatal) • Up to 12% of every pregnant & postpartum women experience depression per year • Prevalence doubled for low income women (Leung & Kaplan, 2008; Earls et al., 2010)

27. Study 1-Depression during pregnancy • Objective: Study the prevalence and risk factors associated with depression during pregnancy • Country: South Africa • Participants-1062 pregnant women, 18 & over • Depression- measured using Edinburg Postnatal Depression Scale • Mode of data collection: Interview • Hartley et al(2011)-Depressed mood in pregnancy: Prevalence and correlates in two Cape Town peri-urban settlements

28. Study 1 Measurements • Other measurements: • Age • social support • alcohol and cigarette use during pregnancy • Social support • Parity • Education • Relationship violence in the previous year

29. Study 1 Results • Results • Women who reported previous year partner violence were more likely to experience PD as compared to women who did not experience past year violence • Other risk factors include age, income, and support

30. Study 2-Depression during and after pregnancy • Objectives: • Assess impact of IPV on the course of perinatal depression; • Taking into consideration, the effects of protective and risk factors ; • 4 time periods from pregnancy-13 months post partum • Country: U.S(LA) • Participants:210 Latina pregnant women(IPV vs. No IPV group) • Rodriguez et al.(2010)- Intimate Partner Violence and Maternal Depression During the Perinatal : A Longitudinal Investigation of Latinas

31. Study 2 Data Collection • Mode of data collection: Interviews during pregnancy, 3, 7, & 13 months postpartum • Depression: Measured using the Beck Inventory Fast Screen • IPV: Measured with the Abuse Assessment Screen

32. Study 2 Measurements • Other measurements: • Age • Birth place • Income • Employment • Parity • Education • Partner status

33. Study 2 Results • Results • For IPV and Non-IPV group • Prenatal and Postnatal depression • Highest Depression in prenatal period • Lowest 3 months after delivery • For IPV group(Vs. Non IPV) • Significantly higher depression scores at each time points (at or above cut-off) • Higher cases of persistent depression(scores higher than cut-off at >2 of the 4 time points)

34. PD can also happen after child birth

35. Study 3-Postpartum Depression • Objective: To Explore • The relationship between IPV during pregnancy and health outcomes for the mother and child post partum • Country: U.S (20 Cities) • Participants: 3691mothers • Mode of data collection: Interviews(at delivery and 15 months post-partum) • McMahon, et.al (2011)

36. Study 3 Measurements • Other measurements • Race • Age • Education • Relationship status • Family structure • Parity

37. Study 3 Results • Results • physical & emotional victimization significantly increased the likelihood of depression at 15 months follow-up • Depression scores higher for women who experienced physical victimization alone and those who experienced a combination of physical and emotional • Depression scores lowest in those who experienced emotional victimization alone

38. Study 3 Continued • Other factors: • Married women were less likely to develop depression • Women having their first birth were less likely

39. Conclusion • IPV is a great public health problem • IPV is associated with depression before, during and after pregnancy • Women depressed during pregnancy enter prenatal care late • Depression during pregnancy negatively impacts attachment between mother and fetus and /or infant • Lead to problems cognitive, social, psychological and behavioral development of the child McMahon, et.al (2011)

40. IPV/PD Resource Development Project and Toolkit Cara Finley, MPH Social Solutions International, Inc.

41. Activities – IPV/PD Project 1. A noted need to address the intersection of IPV and PD. 2. EWG Meeting #1 3. Literature Review 4. Needs Assessment 5. EWG Meeting #2 6. Strategic Planning and Toolkit Development 7. Piloting of Toolkit with Healthy Start

42. An Integrated Tiered Approach • PARTNERSHIPS- Focus on reaching out to partners with existing resources and best practices. Assist HS programs in reaching out and building partnerships within their community. • RAISE AWARENESS- Focus on raising awareness about the intersection of IPV/PPD and the importance of streamlined recognition, response and referral. Focus on providing data and support for the need to address IPV/PPD. Incorporate culturally appropriate materials and use a participatory approach. • TRAINING OF HEALTHY START STAFF- Focus on introducing HS to the new Core Competencies (including cultural competence), introducing and training staff regarding best practices/resources/curriculums and how to navigate, use and adapt for their program. Assist with implementation and strategies for sustainability. • RECOMMENDATIONS FOR POLICY CHANGE- Focus on developing Core Competencies and making recommendations to HRSA/Healthy Start for policy changes to incorporate into HS requirements. Use a participatory approach, keeping in mind culturally competent strategies. • IDENTIFY BEST PRACTICES AND EXISTING RESOURCES –Focus on identifying and narrowing down best practices, existing resources and existing curriculums.

43. Tiered Approach Process • Contextual factors influence the work/the activities, and the work we do will in turn influence the contextual factors. • The factors listed relate to challenges identified over the course of the needs assessment including: stigma, belief that there was no intersection of IPV/PD, cultural challenges, limited funding and resources, competing priorities, and lack of leadership support. • Goals: To improve the health and safety of families experiencing intimate partner violence (IPV) and perinatal (PD). • To create new resources to assist Healthy Start (HS) programs in addressing the co-morbidities of IPV and PD. • Inputs: Staff (HRSA, SSi/Altarum, Healthy Start); Partners; EWG; HS Staff; HS clients; Funding; Time; Best Practices; Existing Resources; Webinar technology

44. Tiered Approach Process, cont. • Activities: Research/identify best practices and existing resources; Create policy recommendations; Introduce and train HS staff on new Core Competencies and Resources; Raise awareness, reduce stigma, build confidence among HS staff, leadership and clients; Assist HS in how to build and sustain effective partnerships • Short Term Outcomes: To increase knowledge and awareness of IPV/PD co-morbidities among HS staff and clients; To reduce stigma associated with IPV/PD among staff and clients; To motivate staff and clients to address IPV/PD; To highlight the need to provide services in a culturally competent manner • Intermediate Outcomes: To change HS policy to include concrete recommendations about IPV/PD screening, response and referral; To identify best practices and introduce/assist HS sites in adapting and implementing best practices; To increase confidence and improve the way HS staff respond to and address IPV/PD • Long Term Impact: To improve the health and safety of families experiencing IPV/PD; To improve the way HS programs are able to address IPV/PD in a culturally and linguistically appropriate manner; To reduce the incidence and prevalence of IPV/PD co-occurrence in HS sites.

45. Toolkit Goals • Provide a guide that is culturally and linguistically appropriate to support community-based programs with making the case for why it is important to address the IPV/PD intersection • Assist communities in reducing stigma and provide strategies for building partnerships and increasing support from leadership • To improve the health and safety of families experiencing IPV and PD

46. Toolkit Contents • Assessing if You are Ready • Making the Case • Raising Awareness/Advocacy • Cultural Competency • Building and Sustaining Partnerships • Policy and Legislation • Standards of Care

47. Questions or Comments? Contact Information: Keisher Highsmith, DrPH khighsmith@hrsa.gov Cara Finley, MPH cfinley@socialsolutions.biz Phone: 202-870-2226