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    <recommendedItem id="20100101_19_266"
                     title="Domestic Abuse May Affect Reproductive Freedom (CME/CE)"
                     score="0.003"
                     href="http://www.medpagetoday.com/PrimaryCare/DomesticViolence/tb/18120?impressionId=1265797362821"
                     
      &lt;p&gt;In some abusive relationships, men may use strategies to force women to become pregnant, including sabotaging their birth control, researchers reported.&lt;/p&gt;
&lt;p&gt;In a cross-sectional study of women treated at five family clinics across northern California, about 20% of women said that their partner tried to coerce them into having a child, Elizabeth Miller, MD, of the University of California Davis, and colleagues reported online in the journal &lt;em&gt;Contraception&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Beyond outright coercion, abusive partners also engaged in birth control sabotage, for example, poking holes in condoms and flushing birth control pills down the toilet.&lt;/p&gt;
&lt;p&gt;&quot;It was stunning to have this many women seeking reproductive health services saying, &apos;this has happened to me,&apos;&quot; Miller said.&lt;/p&gt;
&lt;p&gt;To investigate a possible link between domestic violence and forced pregnancy, the researchers conducted a survey of 1,278 women ages 16 to 29 who sought care at the five family planning clinics in northern California.&lt;/p&gt;
&lt;p&gt;More than half of the women surveyed  --  53%  --  reported physical or sexual partner violence.&lt;/p&gt;
&lt;p&gt;Approximately a third of the women who reported partner violence also reported pregnancy coercion or birth control sabotage.&lt;/p&gt;
&lt;p&gt;Altogether, the effect of both partner violence and reproductive control nearly doubled a woman&apos;s odds of unintended pregnancy (OR 1.99, 95% CI 1.11 to 3.58).&lt;/p&gt;
&lt;p&gt;Both pregnancy coercion and birth control sabotage were separately associated with unintended pregnancy as well (OR 1.83, 95% CI 1.36 to 2.46 and OR 1.58, 95% CI 1.14 to 2.20, respectively).&lt;/p&gt;
&lt;p&gt;&quot;The findings suggest that pregnancy coercion and birth control sabotage may be an aspect of partner violence that, given its relevance to reproductive health, should be identified by providers in clinical settings,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;Among the reasons men would want their partners to bear children: &quot;It ranges from things like wanting to leave a legacy, to a straightforward desire for attachment, to having absolute control over her body,&quot; Miller said. &quot;There are all of these elements to it.&quot;&lt;/p&gt;
&lt;p&gt;Aisha Mays, MD, director of the Teen and Young Adult Clinic at San Francisco General Hospital who was not involved in the study, said pregnancy coercion is a growing problem that has been around for &quot;quite some time&quot; but is just now being recognized as a major health issue.&lt;/p&gt;
&lt;p&gt;&quot;It&apos;s about power and control,&quot; Mays said. &quot;It&apos;s another way of saying, &apos;this girl&apos;s taken, this girl&apos;s mine.&apos;&quot;&lt;/p&gt;
&lt;p&gt;Mays said she has seen cases in which a young mother who has a child with another partner will be forced by her new boyfriend to have another baby with him.&lt;/p&gt;
&lt;p&gt;It&apos;s also a way for males to make their partners more dependent on them, according to Amy Bonomi, PhD, MPH, of Ohio State University.&lt;/p&gt;
&lt;p&gt;&quot;Women in abusive relationships are sometimes forced to bear children as a means to keep them dependent on their partner and sometimes as a means to justify additional  --  and sometimes more severe  --  abuse,&quot; Bonomi said.&lt;/p&gt;
&lt;p&gt;Miller said the findings emphasize the need for family planning clinics to provide intervention programs to combat both reproductive control and partner violence.&lt;/p&gt;
&lt;p&gt;Key strategies include advising women about &quot;invisible&quot; forms of birth control such as injectable and intrauterine contraceptives, as well as easy access to emergency contraception.&lt;/p&gt;
&lt;p&gt;&quot;If we can identify that reproductive control is going on,&quot; Miller said, &quot;we can offer the woman methods for birth control that the partner can&apos;t mess with.&quot;&lt;/p&gt;
&lt;p&gt;Mays added that physicians and counselors should talk about women&apos;s empowerment with regard to reproduction during reproductive health visits.&lt;/p&gt;
&lt;p&gt;&quot;It tends to be left out,&quot; Mays said. &quot;We talk about getting the prescription [for birth control] and its side effects. But we really need to have a discussion around whether the girl is feeling ready for sex.&quot;&lt;/p&gt;
&lt;p&gt;The study was limited by its cross-sectional design, which &quot;precludes conclusions concerning temporality regarding associations observed among pregnancy coercion, birth control sabotage, and intimate partner violence with unintended pregnancy.&quot; Miller et al said additional studies are needed to clarify the chronology of reproductive control and partner violence, and how those factors might combine to affect risk for unintended pregnancy.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by grants from the National Institute of Child Health and Human Development, a UC Davis Health System Research Award, and a Building Interdisciplinary Research Centers in Women&apos;s Health award.&lt;/p&gt;&lt;p&gt;The researchers reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_236"
                     title="Prenatal Counseling Reduces Domestic Violence (CME/CE)"
                     score="0"
                     href="http://www.medpagetoday.com/OBGYN/DomesticViolence/tb/18085?impressionId=1265797362821"
                     
      &lt;p&gt;Pregnant African-American women who received counseling to improve their physical and psychological health and safety were less likely to be the victims of domestic violence during pregnancy and postpartum, a new study found.&lt;/p&gt;
&lt;p&gt;Women who received the cognitive and behavioral integrated intervention were less likely to experience recurrent episodes of intimate partner violence victimization (OR 0.48, 95% CI 0.29 to 0.80), according to a report in the Jan. 21 issue of &lt;em&gt;Obstetrics &amp;amp; Gynecology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Counseled women who had reported previous minor intimate partner violence were significantly less likely to experience further episodes during pregnancy (OR 0.48, 95% CI 0.26 to 0.86) and after they gave birth (OR 0.56, 95% CI 0.34 to 0.93).&lt;/p&gt;
&lt;p&gt;Furthermore, counseled women were less likely to give birth very preterm (&amp;lt;33 weeks gestation) than mothers who received no counseling (1.5% versus 6.6% respectively; &lt;em&gt;P&lt;/em&gt;=0.03), and the babies of counseled women had a longer mean gestational age at delivery.&lt;/p&gt;
&lt;p&gt;&quot;A relatively brief intervention during pregnancy had discernible effects on intimate partner violence and pregnancy outcomes,&quot; Michele Kiely, DrPH, of Eunice Kennedy Shriver National Institute of Child Health and Human Development, and colleagues wrote.&lt;/p&gt;
&lt;p&gt;&quot;Screening for intimate partner violence as well as other psychosocial and behavioral risks and incorporating similar interventions in prenatal care is strongly recommended.&quot;&lt;/p&gt;
&lt;p&gt;Intimate partner violence is a pattern of assault and coercion that includes the threat or infliction of physical, sexual, or psychological abuse.&lt;/p&gt;
&lt;p&gt;Approximately 4.8 million episodes of intimate partner violence occur every year in the U.S. in women 18 years and older, according to the CDC.&lt;/p&gt;
&lt;p&gt;Victims are at higher risk for a range of psychobehavioral and health problems, including complications during pregnancy and adverse pregnancy outcomes, such as preterm delivery and low birth weight.&lt;/p&gt;
&lt;p&gt;Kiely and colleagues set out to determine whether a cognitive behavioral intervention administered during pregnancy could reduce intimate partner violence and improve birth outcomes in a population of African-American residents of Washington, DC.&lt;/p&gt;
&lt;p&gt;Of the 1,044 women enrolled in the study between July 2001 and October 2003, 521 were randomly assigned to receive the intervention and 523 to receive usual care. At an initial interview, 336 of the women reported intimate partner violence victimization in the past year, evenly divided between the intervention group and usual care.&lt;/p&gt;
&lt;p&gt;The women in the intervention group received individually tailored counseling and information that addressed the problems they reported.&lt;/p&gt;
&lt;p&gt;The counselors provided information about the types of abuse and the cycle of violence and assessed the level of danger to which the women were exposed.&lt;/p&gt;
&lt;p&gt;They discussed preventive options the women might consider, such as filing a protection order, and the development of a safety plan. The women also received a list of community resources and information on the health risks of smoking and how to cope with depression.&lt;/p&gt;
&lt;p&gt;The complete intervention included eight prenatal sessions delivered during routine prenatal care visits, and researchers conducted follow-up interviews over the phone with the women.&lt;/p&gt;
&lt;p&gt;They found that women in the intervention group who had previously experienced severe intimate partner violence showed a significant reduction in episodes after giving birth (OR 0.39, 95% CI 0.18 to 0.82) and that women who experienced physical violence specifically showed significant reductions by their first follow-up prenatal visit (OR 0.49, 95% CI 0.27 to 0.91) and postpartum (OR 0.47, 95% CI 0.27 to 0.82).&lt;/p&gt;
&lt;p&gt;&quot;There is evidence that this intervention for pregnant African-American women reduced intimate partner violence victimization during pregnancy and improved pregnancy outcome,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;&quot;If generalizable, our results should encourage healthcare providers and third party payers to go beyond screening for psychosocial and behavioral risks to providing services during prenatal care to address such risks. The potential cost savings associated with reduction of births within the highest risk category may be substantial.&quot;&lt;/p&gt;
&lt;p&gt;The authors cautioned that the study was not designed to test whether the intervention was effective at reducing adverse pregnancy outcomes but rather focused on reducing psychobehavioral risks.&lt;/p&gt;
&lt;p&gt;They also noted that only 59% of the women in the intervention group completed all eight sessions, indicating that as a group they were only modestly committed to participating in the program.&lt;/p&gt;
&lt;p&gt;Further improvements to the intervention strategy could be made to address other issues, such as alcohol and drug use, they wrote. &quot;Had we addressed these, we might have been even more successful,&quot; they concluded.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Center on Minority Health and Health Disparities.&lt;/p&gt;&lt;p&gt;The authors reported no financial conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_2444"
                     title="No Benefit Seen in Routine Screening for Domestic Abuse"
                     score="-0.005"
                     href="http://www.medpagetoday.com/PrimaryCare/DomesticViolence/tb/15378?impressionId=1265797362821"
                     
      &lt;p&gt;Screening all women in medical clinics for intimate partner violence in a randomized trial did not reduce rates of abuse or improve their quality of life, researchers said.&lt;/p&gt;&lt;p&gt;Among those for whom the screening revealed a history of abuse, recurrence of partner violence during 18 months of follow-up was reduced by a nonsignificant 18% (odds ratio 0.82, 95% CI 0.32 to 2.12) compared with control participants, according to Harriet L. MacMillan, MD, of McMaster University in Hamilton, Ontario, and colleagues.&lt;/p&gt;&lt;p&gt;The study randomized more than 6,700 eligible and consenting women at 26 Ontario medical clinics to either screening before their medical evaluation, so that interventions could be recommended to women exposed to partner violence, or to completing the screening questionnaires after the clinic visit.&lt;/p&gt;&lt;p&gt;Writing in the Aug. 5 &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;, the researchers found that quality of life scores improved somewhat more at the 18-month follow-up in the screened group  --  from 52.1 to 58.5, compared with an increase from 50.6 to 52.7 in the control group (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05). Depression scores were also modestly reduced.&lt;/p&gt;&lt;p&gt;But when MacMillan and colleagues imputted outcomes for the more than 40% of participants in both groups who dropped out of the study during follow-up, these differences shrank to insignificance.&lt;/p&gt;&lt;p&gt;The screened women also showed no reduction in after-effects of domestic violence, such as post-traumatic stress disorder and drug and alcohol problems, compared with the unscreened group.&lt;/p&gt;&lt;p&gt;&quot;These results do not provide sufficient evidence to support universal IPV screening in healthcare settings in the absence of an effective intervention to prevent or reduce intimate partner violence,&quot; the researchers concluded.&lt;/p&gt;&lt;p&gt;The trial did not employ a specific intervention for those with positive screening results. Clinicians were informed of available local services for victimized women, but they provided referrals at their own discretion.&lt;/p&gt;&lt;p&gt;In fact, the researchers said, &quot;fewer than half [44%] of the screened-positive women reported having a discussion about violence with their clinician during their visit.&quot;&lt;/p&gt;&lt;p&gt;MacMillan and colleagues said it may be argued that even small improvements in outcomes justify screening, particularly as the trial did not identify any specific harms to participants from the screening.&lt;/p&gt;&lt;p&gt;For example, other researchers suggested last year that performing such screens on mothers bringing their children to pediatric clinics would be beneficial. (See &lt;a href=&quot;http://www.medpagetoday.com/PrimaryCare/DomesticViolence/9251&quot; mce_href=&quot;http://www.medpagetoday.com/PrimaryCare/DomesticViolence/9251&quot; target=&quot;_blank&quot;&gt;Pediatricians Should Screen Moms for Domestic Violence&lt;/a&gt;)&lt;/p&gt;&lt;p&gt;But the researchers pointed out that 87% of participants were not exposed to partner violence, suggesting a significant amount of wasted effort in the screening.&lt;/p&gt;&lt;p&gt;They also noted that the screening had a false-positive rate of 11%, requiring additional clinical effort and opportunity costs to identify those with positive results who actually needed no intervention.&lt;/p&gt;&lt;p&gt;In an accompanying editorial, Kathryn E. Moracco, PhD, MPH, of the University of North Carolina in Chapel Hill, N.C., and Thomas B. Cole, MD, MPH, a contributing editor at &lt;em&gt;JAMA&lt;/em&gt;, suggested that the effectiveness of medical screening for partner violence can&apos;t be properly evaluated until there are clinic-based interventions with proven efficacy.&lt;/p&gt;&lt;p&gt;&quot;Specific interventions to prevent the recurrence of abuse for women at risk of violence should be implemented and rigorously tested, preferably in randomized trials, without further delay,&quot; they wrote.&lt;/p&gt;&lt;p&gt;&quot;The results of the [current study] should dispel any illusions that universal screening with passive referrals to community services is an adequate response to violence in intimate relationships,&quot; they contended.&lt;/p&gt;&lt;p&gt;In the study, women presenting at 11 emergency departments, 12 family practice centers, and three ob/gyn clinics during an 18-month period beginning in July 2005 were nominally eligible to participate.&lt;/p&gt;&lt;p&gt;Those younger than 18 or older than 64 were excluded, as were women who did not make their own appointments or who did not have a male partner in the past year. Participation was also limited to those who spoke English, were able to be alone, and were not seriously ill.&lt;/p&gt;&lt;p&gt;These exclusions meant that, of more than 120,000 women presenting at these clinics, about 87,000 were ineligible. Another 13,000 either refused to provide information to determine eligibility or were missed by the investigators. About 1,500 more who were eligible declined to participate.&lt;/p&gt;&lt;p&gt;That left about 6,700 to be randomized. The investigators designated certain days as &quot;screening days&quot; during which all eligible and consenting female patients were asked to complete the screening questionnaire before they saw clinicians. An equal number of days provided the nonscreened control, with participants completing the questionnaire after the clinic visit.&lt;/p&gt;&lt;p&gt;The screening instrument was the Woman Abuse Screening Tool, with the Composite Abuse Scale used to determine exposure to violence during follow-up. Other outcomes such as PTSD, depression, and substance abuse were measured with standard instruments such as the Short Form-12 and Short Form-36. Quality of life was evaluated with the World Health Organization Quality of Life (WHOQOL)&amp;#8211;Bref questionnaire.&lt;/p&gt;&lt;p&gt;Of 2,733 screened patients, 347 had positive results. A similar proportion of the 2,948 patients in the control group who completed the questionnaires also had positive results.&lt;/p&gt;&lt;p&gt;Those in the unscreened group could also be asked about domestic violence if the clinician chose.&lt;/p&gt;&lt;p&gt;Participants were interviewed every six months afterward through the 18-month follow-up period. Attrition was steady, reaching 43% in the screened group and 41% in the control patients at the end of follow-up.&lt;/p&gt;&lt;p&gt;Growth trajectories were calculated with a logistic model for abuse recurrence and with a linear model for quality of life. A secondary analysis used imputed observations based on partial follow-up data to compensate for the high attrition.&lt;/p&gt;&lt;p&gt;The researchers found that, among the screened-positive women still in the study at 18 months, 8% had called a crisis hotline, while 9% had contacted a counseling or advocacy center for abused women, and 4% had sought refuge at a shelter during the follow-up period. Some 26% had talked with a psychologist or social worker.&lt;/p&gt;&lt;p&gt;These figures were very similar to those in the control group whose screening results were positive.&lt;/p&gt;&lt;p&gt;MacMillan and colleagues said it was notable that absolute improvements in most outcomes were seen in both groups relative to baseline.&lt;/p&gt;&lt;p&gt;They speculated that participation in the study  --  being asked about intimate partner violence and its effects  --  may have been beneficial in itself. Every participant was given an information card with details on services for abused women in their communities.&lt;/p&gt;&lt;p&gt;The authors also noted that the study began during a period when crime statistics indicated violence was at a high point, and &quot;was likely to decrease over time regardless of any intervention.&quot;&lt;/p&gt;&lt;p&gt;Besides the high loss to follow-up, limitations to the study included the reliance on participant self-report for baseline and follow-up data, as well as the carefully controlled trial conditions that would probably not occur in ordinary medical practice.&lt;/p&gt;&lt;p&gt;They also noted that significant costs were involved to support the highly trained research assistants who ensured that women filled out the written screen and that positive results were delivered immediately to the clinicians. In addition, each clinician received specific training.&lt;/p&gt;&lt;p&gt;Also, the study was conducted in Canada where women have universal access to most healthcare services.&lt;/p&gt;&lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt;The study was funded by a grant from the former Ontario Women&apos;s Health Council (Ontario Ministry of Health and Long-Term Care).&lt;/p&gt;&lt;p&gt;MacMillan reported holding a Canadian Institutes of Health Research (CIHR) New Emerging Team grant from the Institutes of Gender and Health.&lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_470"
                     title="Partner Violence May Go Unacknowledged by Doctors"
                     score="-0.005"
                     href="