1. family and parenting
2. motherhood
3. pregnancy

Violence Assessment and Follow-up In Public Health Data Sets
Background
Summer, 2012
This project was initiated to explore existing data on assessment of violence in the lives
of women seeking services via the Maternal Child Health (MCH) Funded Perinatal Care
Program (PNCC), the Wisconsin Women, Infants and Children’s Nutrition Program (WIC),
and responding to the Pregnancy Risk Assessment and Monitory Survey (PRAMS). In
addition, the documentation of referrals for violence, when violence was identified as a
risk factor, was evaluated. Project outcomes included:
1. To establish baseline measure of how often and when women are asked the
questions pertaining to violence on assessments for WIC or MCH/Medicaid
funded (PNCC) services.
2. To determine patterns of referral for women responding that there is
interpersonal violence in their lives.
3. Analyze and monitor responses in PRAMS to questions of abuse before, during
and after pregnancy.
4. Create an effective information campaign targeted at public health
professionals working with clients enrolled in WIC and MCH/PNCC.
5. Create resources for public health professionals to assess and refer clients.
6. Continue to monitor and evaluate public health performance in assessing and
responding to violence in client lives.
7. To establish policy recommendations for systems change to normalize standards
of assessment and referral for violence in public health settings.
Violence is shown to be associated with a wide-range of impacts on the health and wellbeing of individuals and communities. Violence and abuse is an unrecognized
underlying cause of acute and chronic disease, early mortality, high risk behavior
choices, and can threaten academic success and economic stability. Additional research
has identified the impact of constant stress on the architecture of the developing brain
that results in changes in social, emotional, cognitive, and neurobiological function.
Exposure to violence, whether current or past, is linked to reproductive coercion,
sexually transmitted disease, teen pregnancy, poor pregnancy and birth outcomes,
compromised infant child bonding, and a decrease in the level of parenting skills. It is
our hope, that by demonstrating this through Wisconsin’s current data collection
systems, that public health practice will grow in its consideration of violence as a
determinant of health.
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Related Data About Violence Among Women in Wisconsin
National Intimate Partner and Sexual Violence Survey (NISVS) 1 results report national
and state level data on lifetime experiences of rape, physical violence and/or stalking.
According to NISVS, 36% of women in the United States reported these experiences, and
48% of women have experienced at least one form of psychological aggression, either in
the form of expressive aggression (partner acted angry in a way that seemed dangerous)
or coercive control (limiting money, contacts, or access to contraception). (Table 1)
Table 1: Estimated Victimization of Sexual Assault, National Intimate Partner and
Sexual Violence Study, 2010
Lifetime Prevalence
Rape, Physical Violence,
and/or Stalking by Intimate
Partner
National
Prevalence
Wisconsin
Prevalence
36%
32%
Equals 714,000
Wisconsin women
> 18 years
Adverse Childhood Experiences (ACE) Study and related research 2 provides
information on the prevalence of violence in the lives of children and correlations to
health outcomes as an adult. (Figure 1)
Figure 1
Participants completed a confidential
The ACE Study began in 1997 as
survey about experiences of childhood
collaboration between Kaiser Permanente
maltreatment and family dysfunction; a
HMO and the Centers for Disease Control
and Prevention. It recruited over 17,000
positive answer to a question is a point
patients enrolled in the San Diego area
towards an ACE score, with significant
undergoing routine physical examinations.
correlation to compromised health
(www.cdc.gov/ace)
outcomes at an ACE score of 4 or more.
Participants approved access to their
medical records, providing researchers with a wealth of information to examine ACE
experiences and multiple mental, physical, behavior outcomes, and on academic
achievement, financial and social stability. In 2010 an ACE Module was added to the
Wisconsin Behavior Risk Factor Survey. In 2012, a report of the first year of data was
released, documenting that 56% of the adult population reported having experienced at
least one ACE, and 14% have a score of 4 or more ACEs 3 (Table 2)
1
Center for Disease Control and Prevention, National Intimate Partner and Sexual Violence Survey
(http://www.cdc.gov/ViolencePrevention/NISVS/) 2010
2
Adverse Childhood Experiences Study, Center for Disease Control and Prevention, cdc.gov/nccdphp/ACE
3
O’Connor, C., Finkbiner, C., Watson, L. (2012) Adverse Childhood experiences in Wisconsin: Findings from the 2010
Behavioral Risk Factor Survey, Madison, WI: Wisconsin Children’s Trust Fund and Child Abuse Prevention Fund of
Children’s Hospital & Health System. (www.wichildrenstrustfund.org)
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Table 2: Wisconsin and National ACE Scores
ACE SCORE
ACE score of at least one
ACE score of four or more
Kaiser Study
Wisconsin, 2010
64%
12%
56%
14%
ACEs in Wisconsin are equally distributed among males and females, except for sexual
abuse where 16% of women reported being sexually abused and 7% of men (Figure 2).
ACEs occur in clusters, with 61% of those reporting one ACE also reporting two or more.
Certain ACEs tend to indicate a greater likelihood of other traumatic experiences. For
example, among adults who as a child lived with a parent or other household member
who was in jail, 69% have four or more ACEs.
Figure 2: Prevalence of Individual ACEs in Wisconsin, 2010
Incarcerated Household Member
6%
Sexual Abuse
11%
Mental Illness in Household
16%
Violence between Adults
16%
Physical Abuse
Separation/Divorce
Substance Abuse in Household
Emotional Abuse
17%
21%
27%
29%
Source: Adverse Childhood Experiences in Wisconsin: Findings from the 2010 Behavioral Risk Factor Survey
Violence and Pregnancy in Wisconsin
Multiple public health programs focus on the needs of pregnant women, babies and
children. Violence has a direct impact on outcomes for those populations. Healthy
pregnancies, including the choice to become pregnant, can be compromised by
exposure to violence as a child or adult. Children born into environments of violence
have an ACE Score of at least 1 at birth. Current literature on violence and pregnancy
indicates that:
•
Violence can influence when and how a pregnancy occurs (pregnancy coercion,
birth-control sabotage, control of pregnancy outcomes). 4
4
Miller, Elizabeth and Silverman, Jay G., “Reproductive coercion and partner violence: implications for clinical
assessment of unintended pregnancy”, Expert Review of Obstetrics & Gynecology, September 2010.
Violence Assessment and Follow-up Documented for Clients in of WIC-ROSIE, Prenatal and Postpartum Assessments in
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•
•
•
•
•
•
•
Pregnancy itself can evoke initiation or increases in violence.
Pregnancy may also shield a woman from violence, which may provoke multiple
and frequent pregnancies as a form of protection.
Experiences of violence and coercion are common among pregnant teens 5.
ACE was associated with 19% of men involved in a teen pregnancy. 6
Women who have experienced violence while pregnant or before may have
prolonged hormonal levels related to “fight or flight” reactions; these cross the
placenta and can impact fetal brain development and chemical balance that
affect cognition and behaviors throughout life.
Pregnant women in abusive relationships are at higher risk of late entry into
prenatal care, low maternal weight gain, infections, high blood pressure, vaginal
bleeding, and maternal stress.
Homicide is emerging as a leading cause of pregnancy-related deaths.
Child sexual abuse or experiences of sexual violence as an adult can inform the
experiences of pregnancy, labor, delivery and mother/infant bonding.
• Memories triggered by touch and examinations during prenatal care may delay
seeking services.
• The process of labor itself can trigger memories of abusive experiences and loss
of control.
• Responses to labor may be “out of proportion” and may prolong the duration.
• Post-partum adjustment to infant demands can mimic the control an abuser had
and decrease infant bonding.
• Infant care during the night may bring back experiences of nighttime abuse.
In February 2012, the American Congress of Obstetrics and Gynecology released a
committee opinion that called for physicians to “screen all women for intimate partner
violence at periodic intervals, including during obstetric care (at the first prenatal visit,
at least once per trimester, and at the postpartum checkup), offer ongoing support, and
review available prevention and referral options.” 7 Expanding to include assessment of
experiences of violence of the pregnant women from childhood with follow-up can help
to prepare clients for some of the negative responses noted above.
SPHERE Documents Assessment and Referral of Violence among MCH PNCC Clients
The Secure Public Health Electronic Record Environment (SPHERE) is used by agencies
receiving MCH Block Grant funds to document perinatal care coordination and also by
some agencies providing Medicaid Prenatal Care Coordination services. During 2008 –
5
Hills, SD, et al, “The Association Between Adverse Childhood Experiences and Adolescent Pregnancy, long term
psychosocial consequences, and fetal death, Pediatrics, February 2004.
6
Anda, RF, et al. “Adverse Childhood Experiences and Risk of Paternity in Teen Pregnancy, Obstetrics and Gynecology,
2002.
7
American College of Obstetricians and Gynecologists, Committee Opinion, Committee on Health Care for
Underserved Women, Intimate Partner violence, #418, February, 2012
Violence Assessment and Follow-up Documented for Clients in of WIC-ROSIE, Prenatal and Postpartum Assessments in
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2010, 19% of women screened on prenatal assessment reported experiences of violence
(Table 3).
Table 3: SPHERE Results, Women Assessed for Violence, 2008-2010
SPHERE Question
Have you ever been physically, sexually, verbally,
or emotionally abused by a partner or someone
close to you?
Referral made within 30 days of a prenatal or
prenatal ongoing assessment indicating abuse.
Results in postpartum assessment are 2010 only.
Missing or unknown
Yes response,
Prenatal
Assessment*
Yes response,
Postpartum
Assessment**
2,282
116
19%
2%
48
In 2010, for the 40
Yes responses to the
question:
8 were referred
2 were not
11 declined
6 receiving services
13 missing/blank
2%
205
1,154
2%
13%
*12,134 unduplicated prenatal clients
**8,693 unduplicated postpartum clients with at least one prenatal initial or prenatal ongoing monitoring
300 days earlier or less indicating abuse.
As anticipated, women who reported experiences of abuse were at higher risk for
behaviors and conditions that can complicate pregnancy and care-giving (Table 4).
Women who experienced abuse report higher levels of concern about money, job
security for themselves and their partner, concern about their own and their partners
drinking or drug use, and having partners who were in jail. The children born into these
environments, by definition, have at least one ACE.
Table 4: SPHERE Results, Women Assessed for Prenatal and Postpartum Services,
2008-2011
Prenatal/Postpartum Assessment
Question
Abused*
Not Abused*
Before pregnancy, did you smoke cigarettes?
62%
44%
Since you have been pregnant, have you smoked
cigarettes?
46%
28%
Since your pregnancy ended, have smoked
cigarettes?
44%
21%
Violence Assessment and Follow-up Documented for Clients in of WIC-ROSIE, Prenatal and Postpartum Assessments in
SPHERE, and PRAMS
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Prenatal/Postpartum Assessment
Question
Abused*
Not Abused*
In the three months before your pregnancy, did you
use any form of alcohol?
54%
38%
Since you have been pregnant have you used
alcohol?
14%
7%
Since your pregnancy ended, have you used
alcohol?
19%
7%
Have you had problems with depression or received
counseling or medications for mental health
concerns? (prenatally)
66%
27%
Since your pregnancy ended, have you been
bothered by feeling down, depressed, or hopeless?
48%
11%
Prenatally, rates current stress level “High”.
30%
13%
Postpartum, rates current stress level “High”.
36%
7%
*Abused is a positive response to “Have you ever been physically, sexually, verbally, or emotionally
abused by a partner or someone close to you?” Not Abused is a negative response to the question.
ROSIE Documents Assessment and Referral of Violence Among WIC Clients
The ROSIE data system is used by Wisconsin Women, Infants, and Children (WIC) Clinics
to collect data required by the US Department of Agriculture, and to evaluate and direct
program planning. WIC provides nutritious foods, nutrition education (including
breastfeeding promotion and support), and referrals to health and other social services
to participants at no charge. WIC serves low-income pregnant, postpartum and
breastfeeding women, and infants and children up to age 5 who have a nutrition risk
and meet income guidelines. Initial and ongoing assessments of nutrition risk are made
by the WIC certifier. Victim Battering (defined as violent physical assaults on the
woman) is a WIC nutrition risk factor, and is determined by the response to the health
assessment question “How do you rate your current stress level?” If the WIC applicant
states that their stress level is medium or high, the WIC certifier may ask a probing
question as to why she said that. If the participant shares that battering is the reason,
and it occurred within the past 6 months, the certifier can assign the victim battering
risk factor. This question is not required as part of the nutrition risk assessment, and
consequently it is not consistently asked across the state. Because of the lack of
denominator there is no opportunity to calculate a percentage or rate of WIC clients
who respond that they have been battered. Information about referrals is similar; from
2008-2011, there were 118 referrals made for domestic abuse, but again a denominator
is lacking as to how many women were asked about referrals or reported battering.
Referrals are recorded separately and not necessarily linked to the battering risk factor.
Violence Assessment and Follow-up Documented for Clients in of WIC-ROSIE, Prenatal and Postpartum Assessments in
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Figure 3 shows how many women seen prenatally at WIC were assigned the Victim
Battering risk factor and how many seen at postpartum visit, by year. In 2011, 249 WIC
clients reported violent physical assault in the previous 6 months at prenatal assessment
and 179 at postpartum assessment.
Figure 3: Women Enrolled in WIC reporting Victim Battering, ROSIE, 2008-2011
From 2008-2010 about 13,000 women received prenatal services annually and 15,000 were seen for postpartum visits.
PRAMS Documents Assessment and Referral for Violence Among Postpartum Women
The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing, state and
population-based surveillance system designed to monitor selected maternal behaviors
and experiences that occur before, during, and after pregnancy among women who
deliver live-born infants in Wisconsin. PRAMS employs a mixed mode data-collection
methodology; up to three self-administered questionnaires are mailed to a sample of
mothers, and non-responders are followed up with telephone interviews. Self-reported
survey information is linked to selected birth certificate data. PRAMS provides data not
available from other sources about pregnancy, birth outcomes, and the first few months
after birth (Table 5).
Table 5: Wisconsin PRAMS 2007-08
PRAMS QUESTIONS
During the 12 months before you got
pregnant, were you:
Pushed, hit, slapped, kicked, choked or
physically hurt in any way by an exhusband or ex-partner?
Physically hurt in any way by your husband
or partner?
During your most recent pregnancy, were
you:
Pushed, hit, slapped, kicked, choked or
physically hurt in any way by an exhusband or ex-partner?
Total
% positive responses
White Black
Hispanic
Other
4.6%
3.6%
12.1%
6.7%
4.9%
3.8%
2.6%
10.3%
5.9%
4.7%
2.7%
1.9%
7.1%
3.0%
4.9%
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PRAMS QUESTIONS
Physically hurt in any way by your husband
or partner?
Total
2.8%
% positive responses
White Black
Hispanic
2.0%
6.5%
3.8%
Other
3.9%
Source: Wisconsin PRAMS Pregnancy Risk Assessment Monitoring System, 2007-2008, Bureau of Community Health Promotion and
Office of Health Informatics, Division of Public Health, Wisconsin Department of Health Services
The PRAMS data differs from ROSIE and SPHERE in two important ways. The PRAMS
respondents are a random sample of all mothers who gave birth, inclusive of all socioeconomic levels; the WIC and PNCC programs have income eligibility requirements for
participation. The PRAMS survey is completed by the individual within the privacy of
their home; the WIC and PNCC assessments are generally done in a clinic setting, most
often via an interview. The PRAMS questions probe more deeply at when violence was
experienced, and by whom.
Conclusion and Recommendations
The implications for ignoring experiences of violence in the lives of women has both
immediate impact — increased risks for complicated labor and delivery, child
maltreatment, low birth weight, homicide — and life-time implications related to risk
behavior choices, compromised medical and physical health outcomes, social and
economic instability for both the mother and child. Mothers with ACEs are at higher risk
of perpetuating the cycle of ACE experiences. Children born into a home where violence
is occurring, where at least one member of the household is in jail, has mental health
issues, uses drugs or drinks, begin life with at least one adverse childhood experience,
are at a higher risk of raising that score, and inherit the burdens that often come with
ACEs.
The cost of not assessing and responding to experiences of violence is high and longlasting. Public costs of low birth weight and pre-term infants is documented, as are the
costs for treatment and recovery, incarceration, mental and physical health
interventions, increased dependence on public support, and lower education and the
resulting opportunities for income and employment stability. These costs continue as
more children are born into these experiences and the cycle continues.
Public health addresses a number of the areas that result from experiences of violence.
Public health emphasizes prevention. Addressing violence is a strategy that is far
“upstream” in the prevention continuum encompassing both prevention and
intervention. It breaks the cycle of violence and abuse, and promotes the skills for
supportive parenting and the growth of healthy and centered children.
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Recommendations
The following recommendations are directed at systems level change in identifying,
responding to, and preventing trauma. The system can be at any level: Programmatic,
community, agency, state or local.
1. Increase use and documentation of questions related to experiences of violence for
women seeking public health services.
a. Revise PNCC/WIC questionnaires and schedules to assure compliance with
ACOG protocol (experiences of abuse assessed at prenatal visits, once per
trimester, and the postpartum checkup).
b. Establish performance measures or competencies based on timely
assessment, referral, and follow-up.
c. Consult with DHS Division of Access and Accountability to consider the use of
violence related and/or ACE questions on PNCC assessments.
2. Promote the assessment of childhood experiences for adult clients as a tool in
strengthening and supporting recovery, creating positive environments for children.
a. Explore opportunities for the revision of existing questionnaires to
incorporate ACE questions or expand assessment of experiences of violence
across a lifetime.
b. Promote evaluation of ACE responses to other assessed outcomes.
c. Provide information on models for screening for violence in public health
settings, including technology.
3. Increase capacity for assessment, referrals and follow up.
a. Promote training on trauma-informed care.
b. Develop guides for a community referral/response matrix for trauma.
c. Explore use of initiatives for trauma informed foster parenting as a model for
training of public health staff.
4. Continue with data collection and analysis of assessment and referral of
interpersonal violence in public health settings.
a. Promote the regular use of SPHERE and WIC report function to provide
regular assessment of data.
b. Utilize ongoing analysis of PRAMS data related to reports of violence and
prenatal/postpartum experiences.
c. Consider an annual report utilizing this information as baseline to evaluate
systems and outcome changes.
d. Promote evaluation of documented experiences of violence with health
outcomes through multiple data sources.
Violence Assessment and Follow-up Documented for Clients in of WIC-ROSIE, Prenatal and Postpartum Assessments in
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Program staff in the Bureau of Community Health Promotion contributing to this
report:
WI Women, Infants, and Children’s Nutrition Program, Connie Welch, Jodi Klement
Secure Public Health Electronic Records Environment, Susan Kratz
MCH funded Prenatal Care Coordination, Katie Gillespie
Pregnancy Risk Assessment Monitoring System, Kate Kvale
WI Injury and Violence Prevention Program, Sue LaFlash
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