Consensus Study Highlights  | JANUARY 2024

Essential Health Care Services Addressing Intimate Partner Violence

Committee on Sustaining Essential Health Care Services Related to Intimate Partner Violence During Public Health Emergencies

Intimate partner violence (IPV) affects nearly half of women in the United States (Brieding et al., 2015)

This abuse has serious adverse effects on their physical and mental health. When disaster strikes, these women face compounding physical and psychological trauma. The National Academies of Sciences, Engineering, and Medicine’s Committee on Sustaining Essential Health Care Services Related to Intimate Partner Violence During Public Health Emergencies was tasked with identifying the essential health care services for women experiencing IPV during steady state conditions, determining whether that list differed during public health emergencies, and identifying strategies to ensure women can access this essential care when disaster strikes.

Rescuer taking care of patient, preparing her for transport.

IPV refers to abuse or aggression committed by a current or former intimate partner (Brieding et al., 2015). This abuse affects women of all races and ethnicities, all levels of income, and all sexualities, and people of all gender identities, regardless of whether they live in rural, suburban, or urban areas. Women experiencing this abuse have complex health needs that continue after the abuse ends.

Public health emergencies (PHEs) are situations with health consequences whose scale, timing, or unpredictability threatens to overwhelm the routine capabilities of the affected geographic area. They include infectious disease outbreaks; extreme weather events such as hurricanes, heat waves, wildfires, and earthquakes; and technological disasters such as mass power outages or oil spills.

PHEs are associated with increased frequency and severity of IPV.

KEY FACTS

  • The most common and serious health consequences of IPV
    • Facial fractures and other injuries to the head, face, and neck, including dental injuries, traumatic brain injuries, and injuries from strangulation. (Black, 2011; Loder and Momper, 2020; McCarty et al., 2020; Patch et al., 2021; Pritchard et al., 2017; Rajandram et al., 2014)
    • Musculoskeletal injuries, particularly upper extremity fractures. (Tang et al., 2023)
    • Gynecologic and reproductive health effects including sexually transmitted infections, HIV infection, unintended pregnancy, and rapid repeat pregnancies. (El-Bassel et al., 2022; Ely and Murshid, 2018; Moore et al. 2010)
    • Pregnancy complications including preeclampsia; preterm delivery; and fetal, neonatal, and maternal death. (Alhusen et al., 2014; Auger et al., 2020; Loeffen et al., 2016; D’Angelo et al., 2023; Donovan et al., 2016; Guo et al., 2023)
    • Mental health conditions such as posttraumatic stress disorder, anxiety, depression, substance misuse, suicidality, and eating disorders. (Beydoun et al., 2017; Black, 2011; Dichter et al., 2017; Dokkedahl et al., 2022; Lacey et al., 2015; Termos et al., 2022; White et al., 2023)
    • Chronic pain. (Walker et al., 2022)
    • Intimate partner homicide, particularly during pregnancy. (Campbell et al., 2021; Noursi et al., 2020)
  • IPV, particularly reproductive coercion and sexual abuse, are associated with unintended pregnancy
    • Unintended pregnancy is significantly associated with adverse maternal and infant outcomes, including maternal depression during pregnancy, postpartum depression, preterm birth, and low birth weight (Nelson et al., 2022).
    • Unintended pregnancy has also been identified as a risk factor for experiencing IPV during pregnancy (D’Angelo et al., 2023; Smith et al., 2023).
    • Experiencing IPV during pregnancy is associated with several serious adverse maternal and infant health outcomes, as well as intimate partner homicide (D’Angelo et al., 2023; Donovan et al., 2016; Guo et al., 2023).
  • Women access and receive health care services for IPV through multiple pathways and in a variety of settings.
    • IPV may be detected during a visit with a health care provider, whether for treatment of IPV-related injuries or through a woman’s disclosure to her clinician during IPV education and screening.
    • They may engage with support services through advocacy programs, IPV and domestic violence shelters, hotlines and support groups, or other community-based programs and may be referred to the traditional health care setting for care.
    • Their clinician may refer them to a community-based organization for care.
    • They may be referred to the traditional health care setting and community-based organizations for care by the criminal justice system, school-based programs, or other community support service providers.
    • These pathways may not be “one way,” but instead represent bidirectional referral relationships. Figure of pathways representing bidirectional referral relationships view larger
  • The World Health Organization developed the following list of high-priority categories of essential health care services during the COVID-19 pandemic (WHO 2020)
    • Essential prevention measures for communicable diseases, including immunizations
    • Services related to reproductive health, including during pregnancy and childbirth
    • Core services for vulnerable populations, such as infants and older adults
    • Provision of medications and supplies to support the ongoing management of chronic diseases, including mental health conditions
    • Uninterrupted critical inpatient care
    • Management of emergency health conditions and common acute presentations that require time-sensitive intervention
    • Auxiliary services, such as basic diagnostic imaging, laboratory, and blood bank services

Those responsible for planning and providing health care on the front lines of PHEs usually have limited knowledge about IPV and IPV care providers often have limited knowledge about PHE planning and response.

  • IPV Key Facts
    • IPV can include, but is not limited to, physical violence, sexual violence, stalking, psychological aggression, and reproductive coercion. (ACOG, 2012; Brieding et al., 2015) 
    • IPV is common among adolescents and many adults report that they first experienced IPV before the age of 25. (Breiding et al., 2015; Leemis et al., 2022)
    • Women face many barriers to disclosing that they are experiencing IPV, including:
      • Shame or fear of retaliation, including retaliation against their children or losing custody of their children (Cerulli et al., 2014; DeVoe and Smith, 2003; Heron and Eisma, 2021; Heron et al., 2021; Lippy et al., 2019; Meyer, 2010; Othman et al., 2014; Varcoe and Irwin, 2004)
      • Lack of awareness of the supports and services available to them (Ravi et al., 2022)
      • Cultural and religious norms (Hulley et al., 2023)
      • Concern about the safety and well-being of their pets (Campbell and Glass, 2009; Collins et al., 2018)
  • PHE Key Facts
    • An all-hazards approach is a commonly used approach to emergency preparedness and planning that focuses on being ready for any disaster, whether human-made or natural (CMS, 2017). However, an all-hazards approach also includes planning specific to the locale of the service provider. It accounts for the different types of hazards that could potentially occur in a given community (FEMA, 2021).
    • Disaster and PHE declarations at the federal and state level involve several laws and regulations that trigger the release of emergency funding, waivers to some steady state regulations or requirements related to health care services, and communicable disease control powers.
    • The National Disaster Medical System supports state, local, tribal, and territorial response during PHEs by supplementing existing local health and medical system and response staff and supplies.
    • The five phases or steps of emergency management:
      • Prevention—activities undertaken to avoid PHEs
      • Mitigation—actions take to reduce the impact or consequences of PHEs or disasters
      • Preparedness—actions designed to develop resilience and the capability to respond to and recover from the effects of an incident
      • Response—activities undertaken during and immediately after an incident to address its impact directly
      • Recovery—restoration efforts during the longer-term aftermath of an event (DHS, 2015)

Key Recommendations

RECOMMENDATION I

The committee recommends that the Health Resources and Services Administration (HRSA) and all U.S. health care systems classify the following as essential health care services related to IPV …

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RECOMMENDATION V

Essential health care services related to IPV during steady state conditions remain essential during PHEs, but health care systems should restore them in phases that consider the obstacles to delivering this care during different phases of the PHE response.

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RECOMMENDATION VI

HRSA should partner with the Administration for Strategic Preparedness and Response (ASPR) to add an open-access training hub on IPV for disaster health responders and other personnel in health care and community settings that includes education about …

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RECOMMENDATION VII

HRSA should partner with ASPR to develop and disseminate standardized guidance for developing protocols for IPV care for disaster health responders as well as the essential supplies required for delivering that care.

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RECOMMENDATION IX

Federal, state, local, tribal, and territorial governments’ planning should take the following actions to ensure the availability of necessary supplies to deliver essential health care services for IPV during PHEs …

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RECOMMENDATION X

In order to improve consistency in IPV-related terminology used in both the research and clinical setting, HRSA and all U.S. health care systems should adopt the IPV-related terminology defined in the Centers for Disease Control and Prevention’s (CDC’s) Intimate Partner Violence Surveillance Uniform Definitions and Recommended Data Elements.

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Recommendation I

The committee recommends that the Health Resources and Services Administration (HRSA) and all U.S. health care systems classify the following as essential health care services related to IPV:

Recommendation V

Essential health care services related to IPV during steady state conditions remain essential during PHEs, but health care systems should restore them in phases that consider the obstacles to delivering this care during different phases of the PHE response.

The committee defined three phases of PHE response for the purpose of this report, which organize this phased approach.

RESPONSE Initial/ immediate Response operations Stabilization RECOVERY PREPAREDNESS MITIGATION PREVENTION
PHASE WHEN SERVICE SHOULD BE RES T ORED Essential Health Care Service Initial Response ope r ations Stabilization Uni v ersal IPV screening/ inquiry and education Safety planning F orensic medical e xams Emergency medical care T reatment of p h ysical injury Gynecologic and reproducti v e health care including pregnancy termination Obstetric care Urgent Non-urgent P erinatal home visits Cont r aception and emergency cont r aception Cont r acepti v es not requiring procedures or immediate follow-up All types of cont r acepti v es Screening and treatment of s e xually t r ansmitted infections, and HIV T reatment and r apid testing T reatment and all screening Substance abuse treatment Withd r a wal mitigation All treatment Pharmac y / medication management Primary and specialty care Mental health care Urgent / Crisis Non-urgent Dental care Urgent treatment for acute injuries Urgent treatment for acute injuries Support services including shelte r , nutritional assistance, child care Restore services for all patients Selecti v ely restore services for acute needs or restore targeted services Do not restore services during this phase Urgent Non-urgent
Recommendation VI

HRSA should partner with the Administration for Strategic Preparedness and Response (ASPR) to add an open-access training hub on IPV for disaster health responders and other personnel in health care and community settings that includes education about:

Recommendation VII

HRSA should partner with ASPR to develop and disseminate standardized guidance for developing protocols for IPV care for disaster health responders as well as the essential supplies required for delivering that care.

Recommendation IX

Federal, state, local, tribal, and territorial governments’ planning should take the following actions to ensure the availability of necessary supplies to deliver essential health care services for IPV during PHEs:

Recommendation 10

In order to improve consistency in IPV-related terminology used in both the research and clinical setting, HRSA and all U.S. health care systems should adopt the IPV-related terminology defined in the Centers for Disease Control and Prevention’s (CDC’s) Intimate Partner Violence Surveillance Uniform Definitions and Recommended Data Elements. HRSA and other federally funded health care agencies can further support better alignment of clinical and survey data in IPV research by requiring the use of the recommended data elements in their funded projects.

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