Postpartum hospital use among survivors of intimate partner violence.
More than 1 in 3 individuals who identify as female, experience either intimate partner violence (IPV) or sexual assault during their lifetime, and sexual violence committed by an intimate partner is at its highest during their reproductive years.1 As many as 20% of pregnant individuals may experience IPV, and IPV during pregnancy has been associated with an increased risk for adverse maternal and neonatal outcomes, making pregnant individuals an especially vulnerable population.1 In fact, >50% of pregnancy-associated suicides and >45% of pregnancy-associated homicides are associated with IPV and these often occur during the postpartum period.2 Although >50% of maternal deaths occur postpartum,3 little research has examined whether IPV is associated with markers of postpartum maternal morbidity, including hospital readmission and emergency department (ED) visits.4 In addition, few studies have examined the feasibility of ascertaining IPV at the delivery hospitalization using billing codes. Although the International Classification of Diseases, Tenth Revision (ICD-10) codes include factors related to social determinants of health, ICD-10 codes are largely underutilized for the purpose of understanding risk of disease and adverse outcomes.5 The primary objective of this study was to investigate the association of IPV screening at delivery with the incidence of postpartum hospital use. Another objective was to examine the possibility of using ICD-10 codes at the delivery hospitalization to identify IPV in pregnant individuals.
This was a retrospective cohort of birth data linked with inpatient and outpatient hospital claims data, including deliveries of individuals residing in the New York City metropolitan area between 2016 and 2018. Thirty-day hospital use was ascertained by either a readmission or an ED visit within 30 days of discharge. We identified the incidence of IPV from the delivery hospital discharge records using 36 IPV-related ICD-10 codes that we identified in the literature, including those defined for adult psychological and sexual abuse. We estimated the associations between IPV identified during the delivery hospitalization and postpartum hospital use using a multivariable logistic regression and separately adjusting for demographic and structural determinants of health, psychosocial factors, comorbidities, and obstetrical complications. All analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC). This study was approved by our institutional review board.
IPV was indicated on the discharge records of 348 individuals (0.11%). As shown in the Table, the overall incidence of ED visits among individuals with an IPV-related diagnosis was 12.9%. The incidence of a postpartum ED visit was significantly higher among individuals with an IPV diagnosis than among those without (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.1-3.9), and this was true after sequentially adjusting for demographic and structural determinants of health (OR, 2.0; 95% CI, 1.4-2.7), comorbidities and pregnancy complications (OR, 1.9; 95% CI, 1.4-2.6), psychosocial factors (OR, 1.5; 95% CI, 1.1-2.0), and obstetrical complications (OR, 1.5; 95% CI, 1.1-2.0). The incidence of either a postpartum ED visit or readmission was also higher among those patients with an IPV-related diagnosis (OR, 2.7; 95% CI, 2.0-3.6). However, there was no significant difference in postpartum readmissions alone among patients with or without an IPV-related diagnosis.
This study established that postpartum ED visits are significantly higher among individuals with an IPV-related diagnosis during the delivery hospitalization in a large citywide database, even after adjusting for established risk factors for postpartum ED use. Because ED visits have been identified as a possible marker of maternal morbidity and mortality,4 this finding may suggest that individuals affected by IPV could benefit from screening throughout pregnancy, including during the delivery hospitalization, to prevent adverse postpartum outcomes. However, as established in this study, IPV identified solely by ICD-10 codes during the delivery hospitalization is rare and likely underreported. It is possible that underdetection of IPV is because of insufficient clinician screening, a lack of documentation in the medical records using ICD-10 codes, and the medical status of the pregnant individual at the time of delivery. This finding demonstrates a need to screen and record findings thoroughly during the pregnancy period, including at delivery hospitalization, for any IPV-related diagnoses. A limitation of our data is that we were not able to ascertain hospital use outside of New York City and did not include other time points during an individual's pregnancy. Future research should identify at which time points IPV screening occurs during care of a pregnant individual and whether this may affect postpartum ED visit rates. As a clinical outcome, maternal mortality is preventable and screening for risk factors such as IPV throughout the perinatal period, including at delivery admission and during the postpartum period, is imperative for comprehensive obstetrics care.
Rao MG
，Stone J
，Glazer KB
，Howell EA
，Janevic T
... -
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Health insurance coverage and experiences of intimate partner violence and postpartum abuse screening among rural US residents who gave birth 2016-2020.
Intimate partner violence (IPV) is elevated among rural residents and contributes to maternal morbidity and mortality. Postpartum health insurance expansion efforts could address multiple causes of maternal morbidity and mortality, including IPV. The objective of this study was to describe the relationship between perinatal health insurance, IPV, and postpartum abuse screening among rural US residents.
Using 2016-2020 data on rural residents from the Pregnancy Risk Assessment Monitoring System, we assessed self-report of experiencing physical violence by an intimate partner and rates of abuse screening at postpartum visits. Health insurance at childbirth and postpartum was categorized as private, Medicaid, or uninsured. We also measured insurance transitions from childbirth to postpartum (continuous private, continuous Medicaid, Medicaid to private, and Medicaid to uninsured).
IPV rates varied by health insurance status at childbirth, with the highest rates among Medicaid beneficiaries (7.7%), compared to those who were uninsured (1.6%) or privately insured (1.6%). When measured by insurance transitions, the highest IPV rates were reported by those with continuous Medicaid coverage (8.6%), followed by those who transitioned from Medicaid at childbirth to private insurance (5.3%) or no insurance (5.9%) postpartum. Nearly half (48.1%) of rural residents lacked postpartum abuse screening, with the highest proportion among rural residents who were uninsured at childbirth (66.1%) or postpartum (52.1%).
Rural residents who are insured by Medicaid before or after childbirth are at elevated risk for IPV. Medicaid policy efforts to improve maternal health should focus on improving detection and screening for IPV among rural residents.
Kozhimannil KB
，Sheffield EC
，Fritz AH
，Interrante JD
，Henning-Smith C
，Lewis VA
... -
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Partner conflict during their index pregnancy and its correlates among a cohort of six weeks postpartum women in Ethiopia.
Current intimate partner violence (IPV) during pregnancy was found to be associated with adverse health outcomes including pregnancy loss, preterm labor, pregnancy complications, hypertension, delivering low birth weight baby, physical injuries and stress. IPV in Ethiopia is considerably high. This study aimed at determining the prevalence of the IPV during the index pregnancy as measured at six weeks postpartum among women in their extended six weeks postpartum period and identify its correlates. Documenting the magnitude of IPV during the index pregnancy as measured six weeks in the postpartum period and identifying factors affecting it could be imperative to generate actionable evidence. Generating such an evidence contributed its share for the Health Minister and other relevant partners in tracking progress towards achievement of the sustainable development goals (SDGs) 5.2.1 by 2030. This study used Performance Monitoring for Action Ethiopian (PMA_ET) merged cohort one baseline and six weeks postpartum data which had enrolled and collected data from currently pregnant women. Frequencies were computed to describe the study participant's characteristics, and chi-square statistics was calculated to assess cell sample size adequacy. Multilevel binary logistics regression statistical modeling was employed to identify correlates of IPV. Results were presented in the form percentages and odds ratio with 95% Confidence Intervals. Candidate variables were selected using p-value of 0.25. Statistical significance was declared at p-value of 0.05. The overall proportion of IPV during the index pregnancy as measured six weeks postpartum was 12.14% (95%CI: 10.66%, 13.79%). A slightly higher percentage of women reported that they have experienced at least one form of sexual IPV 8.09% (95% CI: 6.91%, 9.44%) than experiencing at least one form of physical IPV 6.02% (95% CI: 4.94%, 7.31%). After controlling confounders, the likelihood of experiencing at least one form of physical and/or sexual IPV was 2.14 (95%CI: 1.04, 4.38) times higher among women whose husband had other wives' compared to those who did not have. Women who were residents of Afar region had only 0.14 (95%CI: 0.03, 0.79) odds of experiencing one form of physical and/or sexual IPV. The overall experience of at least one form of physical and/or sexual IPV was found to be 12.14%. A statistically non-significant slightly higher percentage of women reported that they have experienced at least one form of sexual IPV than experiencing at least one form of physical IPV. Activities and efforts which are specific to regions are needed to address the problem of polygamy are hoped to address the problem IPV during pregnancy. Such activities should be tailored along with the maternal and new born care continuum. Further implication of this study is installing violence and contraceptive related preconception care packages in the health system which is imperative in the combat against IPV and any form of gender based violence. In addition, creating institutional capacity in the health system through strengthening and expanding one stop centers to provide medical treatment, care, and psychosocial support along with support for victims and survivors can be considered as imperative. Moreover, the finding gave an insight that installing rapid referral system and linkage to the legal system is key. Similarly, working on early marriage and counseling on childbirth; and spaced pregnancies for those young couples is implied on. Most importantly, determining the prevalence of violence could serve as one of the indicators to monitor the progress towards SDG 5.2.1 and to look for any strategy and policy changes needed in light of the observed progress.
Damtew SA
，Atnafu NT
，Gidey MY
，Sisay TA
，Yohannes M
... -
《Scientific Reports》
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