Maternal stress exposures, reactions, and priorities for stress reduction among low-income, urban women.

INTRODUCTION: Maternal psychosocial stress has been associated with adverse maternal-child outcomes. Vulnerable women's experiences with stressors during pregnancy and their desires and priorities for appropriate and useful stress reduction interventions are not well understood. METHODS: Qualitative interviews with low-income, urban women explored their stress exposures and reactions during pregnancy, ways that stressors overlapped and interacted, and their priorities for stress reduction. Quantitative measures (Perceived Stress Scale; My Exposure to Violence Instrument Danger Assessment; Center for Epidemiologic Studies of Depression Scale, Revised; and Posttraumatic Stress Disorder Checklist-Civilian) supplemented qualitative descriptions of women's stress exposures and reactions. Analyses explored relationships between stressors and women's priorities for stress intervention. Lay advisors from the sample population reviewed qualitative interview guides for appropriateness, completeness, and language prior to interviews and reviewed study findings for validity. Study findings were returned to the community in newsletter form. RESULTS: Twenty-four low-income, urban women participated in interviews. Women in the sample reported high stress, lifetime violence exposure, depression, and posttraumatic stress disorder symptoms. The most common stressors reported were financial strain, violence exposure, and feelings of intense isolation and loneliness. Few participants reported having discussed psychosocial stressors with prenatal care providers. Participants in this study described connections with other women as desirable to relieve their stress and provided input on ways health care providers could facilitate such connections. DISCUSSION: Clinical and research implications of findings are discussed, including approaches that health care providers may find useful to facilitate connections among vulnerable pregnant women.

Prevalence of interpersonal violence against community-living adults with disabilities: a literature review.

OBJECTIVE: To review the empirical literature on the prevalence of interpersonal violence (IPV) against people with disabilities. METHOD: The authors searched for, obtained, and reviewed 6,000 abstracts published between January, 2000 and August, 2010 via searches in PsycINFO and PubMed. Subsequently, 177 potentially applicable full-text articles were independently assessed for inclusion; 22 articles describing 21 individual studies were included in this review. RESULTS: The prevalence of IPV varied depending on the time frame, the definition and type of violence, perpetrator, and disability. Prevalence of any type of IPV among women with disabilities ranged from 26.0%-90.0% for lifetime; 4.9%-29.1% for the past 5 years; and 2.0%-70.0% for the past year. In some studies, when compared to women without disabilities, women with disabilities experienced more lifetime, 5 year, and past year physical and sexual IPV. Prevalence of any IPV in men with disabilities ranged from 28.7%-86.7% for lifetime; 24.9% for the past 5 years; and 36.7% for the past year. CONCLUSIONS/IMPLICATIONS: IPV occurs at elevated and disproportionate rates among women and men with disabilities, especially when assessed over the course of their lives. Future research that relies on standard definitions of disability and violence, uses accessible measurement, and examines IPV in diverse populations of people with disabilities will strengthen future reviews and better inform research and policy priorities on disability and violence.

Facilitators and barriers to disclosing abuse among women with disabilities.

An anonymous audio computer-assisted self-interview (A-CASI) designed to increase awareness of abuse was completed by 305 women with diverse disabilities. Data were also collected about lifetime and past year abuse; perpetrator risk characteristics; facilitators and barriers to disclosing abuse; abuse disclosure to a health provider, case manager, or police officer; and whether a health provider had ever discussed abuse or personal safety. A total of 276 (90%) women reported abuse, 208 (68%) reported abuse within the past year. Women who reported the most abuse experiences in the past year and the most dangerous perpetrators endorsed fewer facilitators and more barriers, but were also more likely to have ever disclosed abuse. Only 15% reported that a health provider had ever discussed abuse and personal safety.

Efficacy of a computerized abuse and safety assessment intervention for women with disabilities: a randomized controlled trial.

OBJECTIVE: To evaluate the effects of a computerized disability-specific abuse assessment intervention on abuse awareness, safety self-efficacy, and safety promoting behaviors of women with diverse disabilities. RESEARCH DESIGN: A randomized control group design was used, with the intervention group completing the assessment intervention both at Time 1 (T1) and 3 months later at Time 2 (T2) and control participants completing it for the first time at T2. Analyses compared intervention and control groups at T2 and evaluated change over time in intervention group participants. The relationship between outcome variables (abuse awareness, safety self-efficacy, safety behaviors) was also explored. RESULTS: The intervention group had greater abuse awareness than the control group at T2, and abuse awareness increased from T1 to T2 among women in the intervention group, particularly among women who had experienced little or no abuse in the past year. Both abuse awareness and safety self-efficacy were significantly related to safety behaviors. CONCLUSIONS: The computerized program offers promise as a nonthreatening method of conducting abuse assessments among women with disabilities while also serving as an intervention to enhance abuse awareness.

Experiences of mistreatment among women with cerebral palsy.

Abuse and mistreatment of women with disabilities is a complex problem that affects their health and well-being. Previous studies have focused on heterogeneous groups of women with disabilities, with only small numbers of women with cerebral palsy included, but different disabilities may play specific roles in relation to abuse. Exploring mistreatment of women with cerebral palsy is important in determining the relationship between mistreatment and a specific disability. The aim of this article was to describe experiences and meanings of mistreatment among women with cerebral palsy. The feminist biographical method was used to provide an in-depth exploration of women's storied lives, uncover the meaning of women's lives from their own perspective, and provide understanding of women whose stories are seldom told. A sample of eight participants participated in two in-depth, audio-recorded interviews. Two major themes and five subthemes emerged. The meaning of mistreatment included participants' definition of mistreatment and their explanation for mistreatment. Outcomes of mistreatment were divided into emotional, social, and physical outcomes. Health care providers need to understand the meaning and outcomes of mistreatment in their patients' lives to begin to address mistreatment, listen to patients, advocate when needed, and provide appropriate health care.

Development of measures of abuse among women with disabilities and the characteristics of their perpetrators.

Three hundred and five women with diverse disabilities completed an anonymous audio computer-assisted self-interview designed to increase women's awareness of abuse. Data were also collected regarding abuse experienced in the past year and the risk characteristics of their perpetrators. Overall, 68% reported some type of abuse. Preliminary evidence for the validity and reliability of questions to assess abuse and perpetrator risk characteristics was found. Latent class analysis revealed four distinct classes of abuse experiences: sexual abuse, physical abuse, multiple forms of abuse, and minimal abuse and three classes of perpetrator risk characteristics: controlling characteristics, noncontrolling characteristics, and minimal risk characteristics.

Interpersonal violence and women with disabilities: analysis of safety promoting behaviors.

Very little information exists related to the interpersonal violence safety promoting behaviors of women with disabilities. Information about women's use of safety promoting behaviors was gathered from 305 disabled and deaf women who completed an anonymous Audio Computer-Assisted Self-Interview. Exploratory factor analyses revealed factors related to seeking abuse-related safety information, building abuse-related safety promoting skills, using relationship support, planning for emergencies, taking legal action, and managing safety in personal assistance relationships. Four of these factors demonstrated significant relationships to women's experience of different forms of abuse and their perpetrator's characteristics.

Development of an accessible Audio Computer-Assisted Self-Interview (A-CASI) to screen for abuse and provide safety strategies for women with disabilities.

To increase safety and minimize the risk of interpersonal violence, it is critical that women with disabilities and Deaf women have an opportunity to identify whether or not abuse is happening in their lives. Awareness and knowledge of what constitutes abusive behaviors is an essential first step in addressing interpersonal violence. This article includes a description of the development and evaluation of the Safer and Stronger Program (SSP), an audio computer-assisted self-interview program, which was created for women with disabilities and Deaf women for the purposes of increasing awareness of abuse, encouraging safety-planning behaviors, and providing information about community resources.

Abuse and psychosocial stress as factors in high utilization of medical services during pregnancy.

High utilization of medical services during pregnancy has not been described as most studies have focused on women who receive inadequate or no prenatal care. This paper describes the characteristics and medical utilization data of 500 pregnant women enrolled in a prospective study. High utilizers (HU), who had a mean of 7.8 utilizations (SD = 3.2), were significantly more likely to be nonwhite, low income, and younger than low utilizers (LU) who had a mean of 0.99 utilizations (SD = 1.1). HU reported a 32% rate of recent abuse compared to 9% for LU. HU also reported significantly more stress, lower self-esteem, and more ambivalence about the pregnancy. Consistent with their higher utilization, they were more likely to be diagnosed with preterm labor, hyperemesis, and gestational diabetes. HU had a higher proportion of complaints of nausea, vomiting, diarrhea, and pain and more mental health diagnoses than LU. Overall, HU were a vulnerable group characterized by recent abuse, economic disadvantage, psychosocial stress, and mental health issues. Their high utilization of medical services may have been due in large part to unmet psychosocial needs.

Abuse disclosure in privately and medicaid-funded pregnant women.

Disclosure of abuse by pregnant women can vary depending on whether the woman is assessed directly by a trained interviewer versus written questionnaires, and if she is asked repeatedly during the course of pregnancy. One thousand pregnant women were enrolled in a randomized clinical trial designed to assess the effects of a nursing case management intervention on the mental and physical well-being of pregnant women experiencing or at risk for abuse. Thirteen percent of the total study participants reported current abuse and/or abuse within the past year, with only 2% of those reporting that the abuse occurred during pregnancy. The incidence of reported abuse was much higher among Medicaid-funded women (28.9%) than privately insured women (8.7%). Regardless of source of payment, women reporting abuse were significantly younger, less educated, nonwhite with lower income, and had significantly higher stress and lower self-esteem than women not reporting abuse. A high incidence of women reporting intimate partner violence described being choked on the Danger Assessment Screen (34%). We strongly urge that choking be added to routine screening questions used during pregnancy and that the Danger Assessment tool is used for further evaluation of women who screen positive. In addition, we believe another barrier to reporting abuse was fear of being reported to child protective services, contributing to the overall low rate of abuse disclosure.

Abuse during pregnancy: current theory and new contextual understandings.

This study used Landenburger's theory, a process of leaving and recovering from an abusive relationship, as a framework to interview 35 pregnant women identified as being at high risk for abuse. Results are reported on 18 women who disclosed active abuse during the study. Landenburger's model was not a good fit. Our participants became trapped and endured violent relationships if they perceived this was the best situation for their unborn child. Additionally the chaos, instability, and lack of resources experienced by these women likely contributed to their inability to complete the four phases described by Landenburger's model for non-pregnant women.

Nurse case management for pregnant women experiencing or at risk for abuse.

OBJECTIVE: To determine whether individualized nursing case management can decrease stress among pregnant women at risk for or in abusive relationships. DESIGN: A multisite randomized controlled trial. SETTING: Two prenatal clinics in the Pacific Northwest and rural Midwest. PARTICIPANTS: 1,000 women who spoke English and were 13 to 23 weeks pregnant at time of recruitment. INTERVENTION: All intervention group women (N = 499) were offered an abuse video and had access to a nurse case manager 24/7. Additionally, participants at risk for or in abusive relationships received individualized nursing care management throughout the pregnancy. RESULTS: The most frequent nursing care management activities were providing support (38%) and assessing needs (32%). The nursing care management group received an average of 22 contacts, most (80%) by telephone and had a significant reduction in stress scores as measured by the Prenatal Psychosocial Profile. Compared to the control group, the differences were in the predicted direction, but not statistically different. A major finding was the choice by abused women to focus on basic needs and their pregnancies rather than the abuse, although all received safety planning. CONCLUSIONS: Pregnant women at risk for or in abusive relationships experience very stressful and complex lives. Nurses need to focus on the needs they identify, which may not be the abusive relationship.

Double binding, abusive intimate partner relationships, and pregnancy.

The purpose of this study was to extend and integrate the process theories of abuse and becoming a mother in order to provide a contextually appropriate perspective for understanding women's behavioural responses to intimate partner abuse during pregnancy. Double binding is proposed as a construct for understanding intimate partner abuse during pregnancy. Double binding refers to the simultaneous and often conflicting psychological and social processes of binding-in to the unborn child and to the abusive intimate partner that women engage in as they perform the developmental tasks associated with becoming a mother while living with an abusive partner. This construct was developed through an inductive-deductive process using clinical experience, a literature review, and qualitative data from 2 studies of abuse during pregnancy. The authors conclude that double binding is a suitable lens through which to interpret pregnant women's behavioural responses to abuse. They offer suggestions regarding clinical practice and research to further develop appropriate interventions incorporating this construct.

Invalidation: a central process underlying maltreatment of women with disabilities.

Recent qualitative studies indicate that maltreatment of women with disabilities by health care providers is a serious quality of care issue. To begin to address this problem, we conducted a secondary analysis of data derived from three qualitative studies of abuse of women with disabilities. Findings identified Invalidation as a central process underlying maltreatment. Invalidation was characterized by health care providers Taking Over care, Discounting, Objectifying, and Hurting women with disabilities during health care encounters. These findings highlight the need to educate health care providers about social and interpersonal aspects of disability and address the problem of Invalidation in health care settings.

Could we have known? A qualitative analysis of data from women who survived an attempted homicide by an intimate partner.

OBJECTIVE: To examine in-depth the lives of women whose partners attempted to kill them, and to identify patterns that may aid in the clinician's ability to predict, prevent, or counsel about femicide or attempted femicide. DESIGN: Qualitative analysis of 30 in-depth interviews. SETTING: Six U.S. cities. PARTICIPANTS: Thirty women, aged 17-54 years, who survived an attempted homicide by an intimate partner. RESULTS: All but 2 of the participants had previously experienced physical violence, controlling behavior, or both from the partner who attempted to kill them. The intensity of the violence, control, and threats varied greatly, as did the number of risk factors measured by the Danger Assessment, defining a wide spectrum of prior abuse. Approximately half (14/30) of the participants did not recognize that their lives were in danger. Women often focused more on relationship problems involving money, alcohol, drugs, possessiveness, or infidelity, than on the risk to themselves from the violence. The majority of the attempts (22/30) happened around the time of a relationship change, but the relationship was often ending because of problems other than violence. CONCLUSIONS: Clinicians should not be falsely reassured by a woman's sense of safety, by the lack of a history of severe violence, or by the presence of few classic risk factors for homicide. Efforts to reduce femicide risk that are targeted only at those women seeking help for violence-related problems may miss potential victims.

Risk factors for femicide in abusive relationships: results from a multisite case control study.

OBJECTIVES: This 11-city study sought to identify risk factors for femicide in abusive relationships. METHODS: Proxies of 220 intimate partner femicide victims identified from police or medical examiner records were interviewed, along with 343 abused control women. RESULTS: Preincident risk factors associated in multivariate analyses with increased risk of intimate partner femicide included perpetrator's access to a gun and previous threat with a weapon, perpetrator's stepchild in the home, and estrangement, especially from a controlling partner. Never living together and prior domestic violence arrest were associated with lowered risks. Significant incident factors included the victim having left for another partner and the perpetrator's use of a gun. Other significant bivariate-level risks included stalking, forced sex, and abuse during pregnancy. CONCLUSIONS: There are identifiable risk factors for intimate partner femicides.

The domestic violence survivor assessment: a tool for counseling women in intimate partner violence relationships.

Seeking to end violence and distress in their relationship is the goal of women abused by intimate partners. The theoretical framework guiding development of the domestic violence survivor assessment (DVSA) was Landenburger's theory of entrapment and recovery. Social context and need to balance care for others and herself influence women's decision-making about abuse. The DVSA was developed collaboratively between researchers and counselors to gain a deeper understanding of battered women's cognitive states in order to assist them during counseling to effectively resolve the dilemma of their abusive relationships while experiencing personal growth. Five states are identified which a woman may experience on 11 issues concurrently at the personal, relationship or social context levels. Research to validate the DVSA and suggestions on use with women desiring to preserve their relationship or preserve their self or preserve the resolution of change is described. Using the DVSA for assessment, intervention and measuring intermediate outcomes is delineated.