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Futures Without Violence eJournal
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Lessons Learned in Implementing a Psychosocial Screener in a High Risk Obstetrics Clinic

Lisandra S. Garcia, MPH1, Ann L. Coker PhD, MPH2, Corrine M. Williams, ScD3, Emily R. Clear, MPH, CHES1, Nancy Jennings, RN, BSN4, Wendy Hansen, MD5, Judith McFarlane, RN, Dr PH, FAAN6, James E. Ferguson, II MD, MBA7


Author’s Affiliations:

1 Research Coordinator, 800 Rose Street, MN 673, Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY 40536, Lisandra.garcia@uky.edu: Corresponding author

2 Verizon Wireless Endowed Chair, Center for Research on Violence Against Women Professor of Epidemiology, Department of Obstetrics and Gynecology, College of Medicine, Department of Epidemiology, College of Public Health, Associate Dean for Research, College of Public Health, University of Kentucky, KY

3 Assistant Professor, 800 Rose Street, C357. Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY

4 Head Nurse, Department of Maternal Care Services, University of Kentucky, Lexington, KY

5 Chair and Associate Professor, the Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY

6 Parry Chair and Professor in Health Promotion & Disease Prevention, College of Nursing, Texas Woman’s University, Houston, TX

7 John M Nokes Professor and Chair of the Department of Obstetrics and Gynecology, University of Virginia School of Medicine, Charlottesville, VA

Acknowledgements:  Authors wish to recognize the financial support for this project by the Department of Obstetrics and Gynecology and the University of Kentucky School Of Medicine.


Self-reported stress and symptoms of depression or anxiety are associated with pre-term delivery and small for gestational age infants. These pregnancy outcomes are risk factors for impaired cognitive and developmental outcomes for infants  (Van de Weijer-Bergsma, Wijnroks, & Jongmans, 2008).  Higher stress and lower economic resources may have a synergistically negative effect on pregnancy outcomes (Rini, Dunkel-Schetter, Wadhwa, & Sandman, 1999).  Highly stressful life events reported during pregnancy are associated with shorter mean gestational age and an increased risk of preterm delivery (Murphy, Schei, Myhr, & Du Mont, 2001; Yost, Bloom, McIntire, & Leveno, 2005).  Abuse during pregnancy, a significant stress-inducing event, is associated with low birth weight, preterm delivery, fetal loss and maternal homicide by a partner (Campbell et al., 1999; Coker, Sanderson, & Dong, 2004; Janssen et al., 2003; Murphy et al., 2001; Silverman, Decker, Reed, & Raj, 2006; Yost et al., 2005).

There is no clear evidence that screening for psychosocial risk factors improve health outcomes for women.  The United States Preventive Health Task Force classified screening as an “I” indicating insufficient evidence to support universal screening for family violence (Nelson, Nygren, McInerney, & Klein, 2004).  However, in a recent prospective, randomized trial, women who received screening and a standardized intervention were noted to have fewer recurrences of violence, a reduced likelihood of a very preterm infant, and an increased mean gestational age (Kiely, El-Mohandes, El-Khorazaty, & Gantz, 2010).  In 2006, the American College of Obstetricians and Gynecologists (ACOG) Committee on Health Care for Underserved Women recommended “screening for psychosocial risk factors at least once each trimester regardless of social status, educational level, or race and ethnicity” (ACOG Committee Opinion No. 343: Psychosocial Risk Factors: Perinatal Screening and Intervention, 2006).  The recent Institute of Medicine report recommended that women’s preventive services include “screening and counseling for all women and adolescent girls for interpersonal and domestic violence in a culturally sensitive and supportive manner” (Clinical Preventive Services for Women: Closing the Gaps, 2011, p. 123).

We present our experience in the implementation of psychosocial screening of pregnant women at their first prenatal care visit at the University of Kentucky Department of Obstetrics and Gynecology.  Special focus is given to the attitudes of health care providers on screening.


Psychosocial screening of all new obstetric (OB) patients was instituted by nursing staff in spring, 2008.  Two groups of patients received prenatal care through the Department of Obstetrics at the University of Kentucky.  One group included high risk patients (defined by a range of health conditions that may negatively influence pregnancy outcomes and referred from providers in central and eastern Kentucky).  The second group was an international population of low risk women, primarily Spanish speaking.

Psychosocial screening included questions about current and lifetime physical, sexual, or psychological abuse, perceived stress, housing instability, unplanned pregnancy, substance use, and depressive symptoms.  Questions were adapted from the ACOG screening guidelines (“ACOG Committee Opinion No. 343: psychosocial risk factors: perinatal screening and intervention,” 2006) along with the Edinburgh Postnatal Depression Scale (Bennett, Einarson, Taddio, Koren, & Einarson, 2004).  Questions were available in both English and Spanish (see Appendix A).  Since none of the nurses were bilingual, three certified Spanish speaking interpreters assisted with screening Spanish speaking patients.  Our nurse manager worked with a hospital information technology team to include the psychosocial screening questions in a newly created electronic medical record.  The chronology of implementation of universal psychosocial screening in our clinic is provided in Table 1.  This project was approved by the University of Kentucky Institutional Review Board. Because psychosocial screening was implemented universally for all new patients, individual consent was not required.  As described in Appendix A, nurses read a statement informing patients of our clinic’s screening policy and to let them know that if child or spouse abuse was disclosed, nurses were required to report these events.

To ensure that nurses were comfortable with asking women about psychosocial risk factors and knew where to refer women who screened positive to specific psychosocial factors, an expert in both psychosocial screening and the health effects of physical and sexual violence on pregnancy outcomes provided an entire day of training using the Abuse During Pregnancy:  Protocol for Prevention & Intervention as an instructional manual (McFarlane, Parker, & Morgan, 2007).  Nursing staff requested further training and expressed the need for addition skills in addressing depression and partner violence with patients.  To address these needs, we organized a year-long seminar series with community-based service providers.  The seminars, which were 45 minutes in length, were offered every other month.  The meetings happened before the normal work shift started; all staff working with obstetric patients were invited (N=8).  Overall, we had 60% attendance for the seminars.   A Universal Screening and Resource Book (see Appendix A) was developed with comprehensive information concerning community resources along with protocols for a positive screen.

A primary objective of this study was to determine the time required from initiation of electronic medical record psychosocial screening until comprehensive screening was achieved (defined as at least 90% of patients screened).  To evaluate the implementation of the psychosocial screening, we performed a retrospective review of all new pregnant women receiving care in the OB clinic with electronic medical records beginning in March 2008 through February 2009.  The clinic administration provided a list of all 534 new patients seen in the clinic between March 2008 and February 2009 to the researchers. One trained graduate research assistant electronically reviewed all 534 medical records.  The review consisted of basic demographic information on the patient (age, race, health insurance status and education level, smoking status in the past 3 months, alcohol consumption and drug use during pregnancy) as well as the patient’s response to each of the psychosocial screening items (see Table 2).  These data were directly entered into an Access database from the electronic medical record. We abstracted medical records at two, six, and 12 months after implementation of the electronic medical record. Additional objectives included assessing the prevalence of positive screens for psychosocial screening.

In an attempt to understand how our health care providers responded to the psychosocial screening, we asked all health care providers with a role in screening  (e.g. registered nurses, resident and attending physicians) to complete an on-line survey using Survey Monkey softwareAll health care providers in the Department of Obstetrics and Gynecology who had direct responsibilities for prenatal care and screening were invited to participate in the electronic survey (n=54).  Providers were sent an email invitation with a link to the Survey Monkey web-site.

Table 1. Chronology of Implementation of Universal Psychosocial Screening
Late February 2008 Electronic Medical Record (SUNRISE) was implemented in the clinic.
March  2008 Psychosocial questions piloted and launched as part of SUNRISE at a routine part of the screening and postpartum visit.
April  2008 Dr. Judith McFarlane conducted a workshop to develop nurses’ skills in: (1) perceiving abuse clues when taking patients’ history; (2) feeling comfortable in screening patients for current and past abuse; (3) providing referrals for patients in need of services.
May  2008 Training nurses regarding the unique attributes of “reporting” associated with mandatory reporting of current spouse abuse in Kentucky (per KSR 209.030, 620.030). This law requires reporting of spousal abuse by any person including health care providers who have reasonable cause to suspect such abuse to the Department of Community Based Services.
July  2008 Conducted an audit of the electronic medical record to confirm that patients were being screened.
August 2008 Universal Screening and Referral Resource Book was made available for health care providers to use in screening, making referrals for the range of psychosocial stressors, and reporting spousal abuse.
August  2008 to  present Series of presentations on community based services were provided to nursing staff and residents to build their knowledge and comfort with screening and making patient referrals. Agencies such as Rape Crisis Centers, Domestic Violence programs, local police department, drug abuse programs, hospital social workers and others were invited.
May 2009 Conducted another audit of electronic medical records to include 534 new patients seen between March 2008 and February 2009, to evaluate the implementation of the psychosocial screener.


Sample Demographics

Seventy percent of our population (n=534) was exclusively Spanish speaking.  Twelve percent of screened women were between the ages of 16 and 19 years, 28% were 20 to 24 years old, 47% were between 25 and 34 years of age and 13% were age 35 or older.  Eighty four percent (n=439) had health care covered through Medicaid and data were missing for 12 women for this variable.

Time to Comprehensive Psychosocial Screening

Progress toward comprehensive psychosocial screening was summarized in Figure 1.  Within two months from initiating comprehensive screening, 75% of all new patients were consistently being screened for housing security, personal safety, and abuse. Screening for depression was not comprehensive until six months; this delay was in part a function of the software programming. Screening for substance abuse was harder to implement because our clinic uses urine screens and these results were already available in the electronic medical record.  Most nurses opted not to additionally query patients about substance use given biologic testing.

Figure 1. Timeline to Implement Psychosocial Screening (N=534)


Frequency of Psychosocial Risk Factors among Screened Prenatal Care Patients

Data regarding the proportion of patients who screened positive for psychosocial risk factors are presented in Table 2.  Among the 534 new patients seen in OB clinics between March 2008 and February 2009, 10.7% disclosed lifetime physical or sexual violence, and 6% disclosed current physical, sexual or psychological abuse (being threatened, stalked, controlled, or “in any other way made you feel unsafe”).  There was no documentation of screening for psychosocial items for 24 women; screening may have occurred but no indication of the patient being screened was noted in the medical record.  Additionally, 3.4% of women felt unsafe in their home, 9.8% of women reported being current smokers, 14.5% reported living with someone who smoked cigarettes, 4.4% reported alcohol use during pregnancy, and 2.1% disclosed illicit drug abuse including use of prescription drugs for recreational purposes.  Having difficulty keeping prenatal care appointments was expressed by 9.5% of screened women.  When asked about the timing of the current pregnancy, 8.5% disclosed that they did not want the pregnancy (not presented in table 2).  Very high current stress levels (5 of 5-point scale) was reported by 7.5% of women screened and 12% had depressive symptom scores of greater than 20 indicating depression on the Edinburgh Depression Scale.  Finally, one or more psychosocial risk factors were reported by 40% of those screened and 7.9% disclosed more than two psychosocial risk factors.

Case Report 1
At her first trimester visit, Patient X, a 28 year-old mother of two, pregnant with her third child, had her first clinic visit at which time the clinic nurse conducted psychosocial screening. This patient screened positive for stalking and current physical abuse. The nurse provided the local hotline domestic violence agencies, described the services available in these agencies, and talked through the personal safety plan. At subsequent clinic visits, staff learned that this patient called the Kentucky Domestic Violence Association (KDVA), moved with her two children to a shelter where she received legal assistance, formally requested a protective order, and has left this partner. When this patient was screened again at her postpartum visit, she indicated that her life had changed for the better; she was out of the shelter, had a job and proudly said: “I can take care of myself and my children, I am not afraid anymore.” This case indicates that patients will disclose abuse when they are ready and will take actions to change their own life situations if screening and referrals are offered by a trusted health care provider.

Qualitative Measures of the Impact of Screening on Patients

Case reports can shed some light on the actual experience of a patient who screened positive for psychosocial factors.  Three brief reports which provide some evidence of the value of screening for individual women are shown in the sidebars.

Health Care Providers’ Perspective on Psychosocial Screening

We invited all 57 nurses, attending physicians, fellows and residents to participate on an online survey via Survey Monkey.  The response rate was 40%.  Of the 23 responding health care providers, 6 were physicians, 6 were nurses, 1 was a fellow, and 10 were residents. Health care providers were asked, “In your opinion, what is the difficulty of screening women for abuse and depression?”  Responses included:  “finding time in busy clinic to screen patients and address positive screenings for depression and abuse,” “asking the right questions to get them to disclose any issues they may be having, and establish a rapport,” “bringing up the issue, especially in the setting of having other persons in the room,” “arranging follow-up with a social worker”, and “language barriers.”

Case Report 2
Patient Z, a 26 year-old woman, was 10 weeks pregnant when she came to the clinic for her first visit. During psychosocial screening, patient Z reveled being extremely sad and helpless because her 7-year-old daughter was abducted approximately one year ago by her ex-partner who was the child’s biological father. The patient disclosed past physical and psychological abuse by this partner for 9 years including his threatening her with a firearm several times. While the patient was in the clinic, we contacted a Kentucky Domestic Violence Associate and they were able to give her legal advice and support to contact the authorities in a foreign country where the daughter was being held and initiate a process to return her daughter. Patient Z delivered a healthy, term infant. This case indicates the value of screening and referrals to improve the well-being of mothers, infants, and other children.

Health care providers were also asked, “What resources would you need to screen your patients for psychosocial risk factors?” Most providers thought that having a social worker in the clinic would reduce the time burden on nurses to provide needed referrals for patients who screened positive for a psychosocial risk factor.  One provider noted, “A social worker or even an on-site counselor to provide immediate help or provide patients with a safety plan.”  Others recognized the additional time associated with conducting psychosocial screening.  Responses included, “It would be most helpful to feel like you did not have to rush because you have so many patients to be responsible for screening in a morning.”

Finally, we asked health care providers whether their patients had disclosed any health benefits of psychosocial screening in terms of health benefits of being screened for abuse or depression.  Fifty percent of nurses and 20% of attending physicians, residents, and fellow residents responded that they thought that their patients benefited from screening.  Health care providers were also asked   whether screening made things worse for their patients.  The majority of both physicians and nurses did not think screening made their patients’ situation worse.

Case Report 3
Patient Y, a 30 year old mother of one who was pregnant with twins, was screened during her initial screening visit. Although this patient did not disclose violence during the screening, the nurse felt that she was on the verge of disclosing. Within the week, patient Y called back asking to speak with the nurse who had screened her. During that phone conversation, patient Y stated that she thought more about the questions and asked that nurse ask these same questions at her next visit. During this visit, Patient Y disclosed increasing emotional abuse from her boyfriend and was worried that it might escalate to physical violence. The nurse provided hotline numbers in case the patient chose to call in the future and together the nurse and patient made a safety plan. This case reinforces the need to ask psychosocial screening questions more than once during pregnancy.


Monitoring the implementation of psychosocial screening using the electronic medical record (EMR) was essential to determining that the screening was universally provided to all new patients.  The EMR was useful as an assessment tool because it made monitoring easier and the EMR was designed so that   answers to the psychosocial screening items had to be provided for the nurse to move to the remainder of the items in the health care visit. This does not mean that the nurses necessarily asked the items requiring answers in the EMR, however this design feature increased the likelihood that the items may be addressed in some way.  Frequent communication with the nursing staff as well as attending physicians to ensure screening was functioning smoothly was very important. Although physicians were supportive of screening, we regularly needed to provide autonomy to the nurses in these screening efforts given the strong external pressure for high patient volume and clinic efficacy.  Physician leadership and support for universal screening was essential for screening rates to remain high.

Some of our findings were similar when compared to data from a national sample but there were also distinct differences.  In our population, 3.9% of women screened disclosed current physical or sexual violence (while not reported in Table 2, all women disclosing sexual violence also disclosed physical violence).  This rate was similar to the 1.8%-6.0% range of physical violence in the prior 12 months reported from 29 states in the Pregnancy Risk Assessment and Monitoring System (“Pregnancy Risk Assessment Monitoring System (PRAMS), Physical  Abuse “, 2008).  The frequency of smoking during pregnancy was in the range of the national PRAMS data (5.1% to 28.7%) (“Pregnancy Risk Assessment Monitoring System (PRAMS), Tobacco Use,” 2008), yet much lower than the 37% that was reported by PRAMS specifically for women in Kentucky (Anderson et al., 2008).  A similar pattern was observed for passive smoke exposure.  This observation may be explained by a lower smoking rate in Spanish speaking women who comprised almost 70% of our clinic population.  Our self-reported rate of alcohol consumption (4.4%) was comparable to the range reported in the national PRAMS of 3.0%-12.1% (“Pregnancy Risk Assessment Monitoring System (PRAMS),Alcohol use,” 2008) and the rate of 5% from Kentucky PRAMS (Anderson et al., 2008). Because universal implementation of screening for depressive symptoms was not in place until August 2008, we restricted analysis to women screened between August 2008 and February 2009 (n=290).  The estimate of depressive symptoms during pregnancy in our clinic was 12.0% which is comparable to those reported in other clinical populations ranging from 7.4%- 12.8% (Bennett et al., 2004). The prevalence of psychosocial risk factors in our population suggests that nurses conducting the screening were asking the questions in a way that pregnant women can and did disclose psychosocial risk factors.

There were many stories of how screening changed our practice, and how psychosocial screening improved women’s lives as described in the three case reports.  Although screening alone may not change the well-being of patients, it does allow disclosure and provides an opportunity for patients to access clinic or community interventions.  Building rapport, providing compassionate responses to disclosure, and making appropriate referrals were crucial to helping women make their best decisions to increase their safety and well-being.

Half of the nurses surveyed indicated that psychosocial screening, particularly abuse screening, was beneficial for OB patients while only 20% of physicians concurred that psychosocial screening was beneficial.  Observing the benefits of screening may be a function of when the questions were asked and who asked the questions.  In our screening protocol, nurses were instructed to conduct all screening in a private setting.  Patient responses were entered into the electronic medical record which physicians all had access to but may or may not have reviewed and thus may not have known the screening results and/or discussed issues of patient safety and well-being.  It is most likely that physicians were aware of screening if the abuse was current and nurses called this disclosure to the physician’s attention.  It is also likely that physicians were aware of the potential problem situations resulting from screening given the additional time needed for the nurse and other staff to counsel the patient and provide referrals before the physician visit could occur.  Physicians were less likely to see the possible benefits of screening that some patients may experience when nurses ask about their safety, well-being and prior abuse experienced.  Asking about violence validates this experience for some women.  Further, asking about violence even among those who have never experienced violence demonstrates knowledge of the frequency and health threat violence does have for many patients.  Through our experience with implementing psychosocial screening in a busy prenatal care setting, we have noted at least four challenges which may be helpful for others implementing psychosocial screening.  The first challenge is unique to states with required reporting laws.  The remaining three challenges are common to the overwhelming majority of prenatal care clinics.

Challenge 1: Mandatory reporting

According to the KRS 209.030, 620.030, the Commonwealth of Kentucky mandates reporting of spousal abuse to the Kentucky Department of Community Based Services (DCBS).  Reports must be made by “Any person, including physicians and nurses, who have reasonable cause to suspect that a child or adult has suffered abuse, neglect, or exploitation.”  Mandatory reporting laws in the state of Kentucky cover any crime committed against a person under 18, all cases of domestic violence, and cases of abuse and neglect of persons over the age of 18 who are “physically or mentally challenged” (“KY Acts ch. 157,” 1976; “KY Acts ch. 423,” 1986).  The primary challenge of this law for psychosocial screening was the additional time required to inform the patient of the law and complying with mandatory reporting requirements for abuse.  The law may have negatively affected patients’ willingness to disclose abuse due to fear of the partner or fear of deportation, given our unique population. To guide health care providers in the reporting process, we created a protocol for health care workers to use in reporting current spousal abuse (physical or sexual). This protocol included a script with the information needed to properly report the abuse by telephone. The following is an example of such a script: “This is Jane Doe, a RN at the XX clinic.  In interviewing Mrs. X, she indicated that in the past 12 months her husband pushed, shoved, slapped, hit, kicked or otherwise physically hurt her.  Her phone number is 222-222-2222.  We are treating her for unrelated conditions.” Our protocol stipulated that the patient be present for this call because women need to be in control of decisions and communications that directly impact their well-being.  While reporting to DCBS is mandatory in Kentucky, a patient can refuse services.  Typically the DCBS sends a letter to an address provided by the health care provider or makes telephone calls to offer referral services.  Women can provide an alternate address to which this letter can be mailed.  Per our screening protocol, we required that all women who screened positive for either physical or sexual abuse be provided with the hotline numbers and web sites for the Kentucky Association of Sexual Assault Program and/or the Kentucky Domestic Violence Programs.  Thus all patients with these needs received this information during the screening.

Challenge 2: Finding a private time/space to safely screen

As is true for many busy obstetrics clinics, family members frequently accompany patients during their health care visits. Because patient safety was of paramount importance, we established a “solo” visit policy. While family members could come to the prenatal care visit, they were not invited into the examination room with the health care provider. On solo visits, nurses asked psychosocial screening questions and provided referrals as needed. This screening was conducted in a private room with only the nurse and patient present. This practice protected the patient as well as the health care provider. It is possible that some partners may become suspicious of the health care providers and/or patients and attempt to locate the patient within the facility. If nurses or other staff perceived any immediate danger, they were instructed to call the security department and a guard would come to the clinic to assist.  During in-service meetings (described in detail below), we worked with local police to obtain the contact information for police detectives who handle domestic violence or sexual assault cases as well as contact information for police domestic violence advocates. Additionally, we worked with hospital security to inform them that we were initiating screening and that it was possible that their assistance might be required. In the year of implementation, we did not need any hospital security or local police support to assist our nursing or physician staff in addressing a hostile partner.

Challenge 3: Finding the time needed to screen and refer patients

We observed that having physician support at the highest level was essential for the continued success and maintenance of psychosocial screening.  Our findings indicate that the issue was not the time to screen the majority of patients (usually less than 2 minutes), but rather the time needed to provide referrals services and conduct mandatory reporting for women who reported current spousal abuse.  Typically, patients who disclosed abuse had more than one other psychosocial stressor thus requiring multiple referrals. Contacting agencies to find services for patients who were depressed and/or abusing drugs was challenging due to the limited number of mental health services for pregnant women.  We also recognized that providing brochures to patients was not the safest or the most effective way to offer referrals.  Therefore, we developed a resource guide to include hotline and web page resources for women experiencing the range of psychosocial risk factors (e.g. violence, stress, substance abuse, depression).  According to our protocol, the patient was given resource phone numbers for domestic and sexual abuse services with no other identifiers that were written on the back of the clinic business card to maintain her safety.  Patients were asked to take the card only if it was safe to so and health care providers reinforced the need for safety planning.

Challenge 4: Building Comfort and Confidence in Nurses Ability to Screen and Refer

Nurses were primarily responsible for conducting the psychosocial screening.  During the training provided on how to screen for domestic and sexual abuse in a health care setting, we received feedback that nurses needed a connection with the service providers to which they would be referring women.  Nurses needed to feel comfortable and confident in referring patients for services.  In response, we provided a staff “in-service” to bring representatives from other community-based referrals to our clinic to meet the staff, present their services, and allow time for clinic staff to ask questions and build rapport.  The first in-service featured the Executive Director of the local domestic violence shelter.  Examples of other in-services included representatives of the local Rape Crisis Center, police, social workers, and in-patient substance abuse treatment facilities.  Our implementation team arranged and attended these meetings. This level of direct communication between the health care team screening patients and the referral agencies was essential in increasing nurses’ comfort and confidence in both conducting the screening and making referrals.  These meetings were also an excellent opportunity to talk with nurses about what was and was not working relative to our goal to implement comprehensive psychosocial screening.  Nurses’ feedback was useful in continued negotiation with administrators regarding time for nurses to screen and provide referrals for women in need of such services.  While the majority of physicians supported efforts to screen and provide resources for patients, the time required for some patients (and some nurses) was problematic.  Continuing efforts to negotiate both additional time and to enhance skills to more effectively screen and effectively refer patients to the range of services were important for both patients and health care providers.

In conclusion, our experience in implementing screening for psychosocial risk factors indicated that screening was feasible and that we were able to establish comprehensive screening in a relatively short time frame.  The majority of both patients and health care providers indicated that screening did not negatively affect patient care and well being.

Table 2. Proportion of 534 Prenatal Care Patients Screened Positive for Psychosocial Risk Factors

Psychosocial Risk Factor

Proportion Screening Positive by Type of Psychosocial Risk Factor (%)

Lifetime† physical OR sexual violence (24 not screened or refused screening)


     Lifetime† physical violence


     Lifetime† sexual  violence


     Lifetime† physical AND sexual  violence


Any current violence (physical, sexual OR  psychological) (24 not screened or refused screening)


     Current psychological violence


     Current physical violence


     Current sexual violence


     Current physical AND sexual violence


Felt unsafe in the their home


Smoking during pregnancy


 Lived with someone who smokes cigarettes


Alcohol use during pregnancy (12 not screened or refused screening)


Illicit drug use (14 not screened or refused screening)


Problems keeping appointments (1 not screened)


High perceived stress: 5 on a 5-point scale (24 not screened or refused screening)


High depressive symptoms score during pregnancy*


Disclosed one or more psychosocial risk factors


     Disclosed 1 psychosocial risk factor


     Disclosed 2 psychosocial risk factors


     Disclosed more than 2 psychosocial risk factors


Mean number of psychosocial risk factors disclosed

0.74 (std = 1.26)

Range 0-9


* Because universal implementation of screening for depressive symptoms was not in place until August 2008, we have restricted this analysis to women screened in August and beyond (n=290 screened).

† Lifetime violence includes current as well as past violence



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Bennett, H. A., Einarson, A., Taddio, A., Koren, G., & Einarson, T. R. (2004). Prevalence of depression during pregnancy: systematic review. Obstetrics and  Gynecology, 103(4), 698-709.

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Kiely, M., El-Mohandes, A. A. E., El-Khorazaty, M. N., & Gantz, M. G. (2010). An integrated intervention to reduce intimate partner violence in pregnancy: a randomized controlled trial. Obstetrics and Gynecology, 115(2), 273-283.

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KY Acts ch. 423, KRS 620.030 C.F.R. § 64 (1986).

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Nelson, H. D., Nygren, P., McInerney, Y., & Klein, J. (2004). Screening women and elderly adults for family and intimate partner violence: A review of the evidence for the US preventive services task force. Annals of Internal Medicine, 140(5), 387-396.

Plichta, S. B., Duncan, M. M., & Plichta, L. (1996). Spouse abuse, patient-physician communication, and patient satisfaction. American Journal of Preventive Medicine, 12(5), 297-303.

Pregnancy Risk Assessment Monitoring System (PRAMS) – Alcohol use. (2008, 11/18/2010). Data for all states for – 2008 – Indicator of whether mother reported having any alcoholic drinks during the last 3 months of pregnancy Retrieved 1/3/2012, 2012, from http://apps.nccd.cdc.gov/cPONDER/default.aspx?page=DisplayAllStates&state=0&year=9&category=2&variable=9

Pregnancy Risk Assessment Monitoring System (PRAMS) – Physical  Abuse (2008, 11/18/2010). Data for all states for – 2008 Retrieved 3/1/2012, 2012, from http://apps.nccd.cdc.gov/cPONDER/default.aspx?page=DisplayAllStates&state=0&year=9&category=1&variable=20

Pregnancy Risk Assessment Monitoring System (PRAMS)  – Tobacco Use. (2008, 11/18/2010). Data for all states for – 2008 Indicator for whether mother smoked during the last three months of pregnancy  Retrieved 1/3/2012, 2012, from http://apps.nccd.cdc.gov/cPONDER/default.aspx?page=DisplayAllStates&state=0&year=9&category=27&variable=31

Rini, C. K., Dunkel-Schetter, C., Wadhwa, P. D., & Sandman, C. A. (1999). Psychological Adaptation and Birth Outcomes: The Role of Personal Resources, Stress, and Sociocultural Context in Pregnancy. [doi:]. Health Psychology, 18(4), 333-345.

Silverman, J. G., Decker, M., R,, Reed, E., & Raj, A. (2006). Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. states: associations with maternal and neonatal health. American Journal of Obstetrics and Gynecology, 195, 140-148.

Van de Weijer-Bergsma, E., Wijnroks, L., & Jongmans, M. J. (2008). Attention development in infants and preschool children born preterm: A review. [doi: DOI: 10.1016/j.infbeh.2007.12.003]. Infant Behavior and Development, 31(3), 333-351.

Yost, N. P., Bloom, S. L., McIntire, D. D., & Leveno, K. J. (2005). A prospective observational study of domestic violence during pregnancy. Obstetrics and Gynecology , 106, 61-65.




Appendix A

University of Kentucky

Psychosocial Screening Tool And Community Resource





Section 1  Introduction

Section 2  Prenatal Screening Tool

Section 3  Community Referrals

Section 4  Safety Planning

Section 5  Victim Services

Section 6  Additional Agencies





Protocol for OB Routine Psychosocial Screening

Staff to conduct:  Nursing staff

When to conduct?

  • At the screening prenatal care visit
  • At each trimester of pregnancy
  • At the postpartum visit

What is included?

  • Introduction
  • Psychosocial screener in Spanish and English
  • Resources for making referrals (e.g. rape crisis, drug use, smoking cessation, suicide ideation or depression)
  • Instructions for required reporting spousal abuse



Read the following text to women who have never completed the psychosocial screener

  • Because we care about your safety and health we are introducing a new set of questions to help us provide the best care we can and to help meet the needs for your own life situation.
  • These may be new questions that have not been asked by other nurses or doctors, but they are an important part of your prenatal care.
  • A few of the questions we will ask will involve the topic of abuse.
  • If during our assessment you tell me that a child in your home is being abused or you tell me that your husband is physically or sexually abusing you, this worries me.  Please know that I am required by Kentucky State Law to report this abuse to the Kentucky Cabinet for Health and Family Services.
  • The purpose of this report is to help you find out about services available in the community.
  • I will make this call with you in the room so that you can talk with them about the services you may want or need.
  • You may refuse services.
  • I can also tell you about these services and help you contact these agencies when you are ready.
  • For your safety your husband will not be informed that this report has been made.


OB Staff


Prenatal Care Screening Tool


1. Do you have any problems (job, transportation, childcare, or others issues) that prevent you from keeping your health care appointments?

  • Yes
  • No


2. Do you feel safe where you live?

  • Yes
  • No


3. In the past 2 months, have you used any form of tobacco?


4. Do you live with someone who smokes cigarettes?

  • Yes[consider mention of tobacco quit line]
  • No


5. In the past 3 months, have you used alcohol (including beer, wine, or mixed drinks)?

  • Yes [consider alcohol and substance abuse referrals]
  • No


6. In the past 3 months, have you used drugs that were not prescribed for you to get high or feel good?

  • Yes [consider alcohol and substance abuse referrals]
  • No


7. In the past 12 months, how many times have you moved (change where you live)?

_____ ____ TIMES


8. On a scale of 1 to 5, how would you rate your current stress level?


1         2         3        4        5


9. If you could change the timing of this pregnancy, would you want it?

  • earlier
  • later
  • not at all
  • no change


As you are pregnant or have recently had a baby, we would like to know how you are feeling.  Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.


10. I have been able to laugh and see the funny side of things

  • As much as I always could
  • Not quite so much now
  • Definitely not so much now
  • Not at all


11. I have looked forward with enjoyment to things

  • As much as I ever did
  • Rather less than I used to
  • Definitely less than I used to
  • Hardly at all


12. I have blamed myself unnecessarily when things do not go well

  • Yes, most of the time
  • Yes, some of the time
  • Not very often
  • No, never


13. I have been anxious or worried for no good reason

  • No, not at all
  • Hardly ever
  • Yes, sometimes
  • Yes, very often


14. I have felt scared or panicky for no very good reason

  • Yes, quite a lot
  • Yes, sometimes
  • No, not much
  • No, not at all


15. Things have been getting on top of me

  • Yes, most of the time I haven’t been able
  • Yes, sometimes I haven’t been coping as well
  • No, most of the time I have coped quite well
  • No, I have been coping as well as ever


16. I have been so unhappy that I have had difficulty sleeping

  • Yes, most of the time
  • Yes, sometimes
  • Not very often
  • No, not at all


17. I have felt sad or miserable

  • Yes, most of the time
  • Yes, quite often
  • Not very often
  • No,  not at all


18. I have been so unhappy that I have been crying

  • Yes, most of the time
  • Yes, quite often
  • Only occasionally
  • No, never


19. The thought of harming myself has occurred to me

  • Yes, quite often (affirmative answers need notation and MD notification)
  • Sometimes
  • Hardly ever
  • Never


(Current Psychological Abuse)


20. During the last 12 months, has ANYONE threatened you, followed you, stalked, controlled your activities or in any other way made you feel unsafe?

  • No
  • Sometimes
  • Yes [for affirmative answers- yes and sometimes, consider referrals for partner violence]

If Yes or sometimes, WHO________________________________________


(Current physical abuse)


21. During the last 12 months, has ANYONE pushed, shoved, slapped, hit, kicked or otherwise physically hurt you?

  • No
  • Sometimes
  • Yes(for affirmative answers- yes and sometimes, consider referrals of partner violence]

If Yes or sometimes, WHO __________________________________________


 (Current Sexual Abuse)


22. During the last 12 months, has ANYONE forced or coerced you into sexual activities?

  • No
  • Sometimes
  • Yes [for affirmative answers- yes and sometimes, consider referrals for victims of partner violence]

If  Yes or sometimes, WHO__________________________________


In answering the next two items, please think your experiences in your lifetime.


23. Has ANYONE pushed, shoved, slapped, hit, kicked or otherwise physically hurt your?

  • No
  • Sometimes
  • Yes [for affirmative answers- yes and sometimes, consider referrals for partner violence]


If  Yes or sometimes, (Just to make sure, you are not including something that happened in the last 12 months)


Did this happen when you were a child (<18 years old)

  • Yes  Child Abuse
  • No    Adult Abuse


24. Has ANYONE forced or coerced you into unwanted sexual activities?

  • No
  • Sometimes
  • Yes [for affirmative answers- yes and sometimes, consider referrals for victims of partner violence]

If  Yes or sometimes, (Just to make sure, you are not including something that happened in the last 12 months)


24.a. WHO__________________________________________


If yes 24.b.  Did this happen when you were a child (<18 years old)

  • Yes            Child Abuse
  • No             Adult Abuse


Community Referrals

Screens positive for (question #)…. Where to refer What else to do
Transportation (#1) Additional counties listed in black Provide local Transportation Service Give OB business card with referral number on the back.
Smoking, active or passive (#3 and #4) Tobacco-Quit linesmokefree.gov 1-800-QUIT-NOW Give OB business card with quit number on back.
Alcohol use (#5) Provide local Alcoholics Anonymous or local alcohol treatment center (see the links below to find local services and free materials):
http://www.cdc.gov/ncbddd/fasd/freematerials.html National Alcohol and Drug Dependence Hopeline at
Give OB business card with referral number on back.
Drug use (#6) Provide local treatment facilities #s (Division of Substance Abuse Services -usually part of the Department of PublicHealth) and ask for a referral near your location)
Local resource locator:
National Drug Help Hotline at
National Alcohol and Drug Dependence Hopeline at
Give OB business card with referral number on back.

Depressive Symptoms (#19)
Psychiatry Service needs to see and evaluate patient to assess risk
National Hotline #s 1-800-784-2433 OR 1-800-273-TALK
Inform MD and make notation in chart.
Current psychological abuse/stalking (#20) National Domestic Violence Hotline
1.800.799.SAFE (7233) 1.800.787.3224 (TTY) http://www.thehotline.org/
Inform MD and make notation in chart.
Current physical abuse  (#21) National Domestic Violence Hotline
1.800.799.SAFE (7233) 1.800.787.3224 (TTY) http://www.thehotline.org/
Inform MD and make notation in chart.
Current sexual abuse (#22) National Sexual Assault Hotline at
1.800.656.HOPE (4673)


National Domestic Violence Hotline
1.800.799.SAFE (7233) 1.800.787.3224 (TTY)

Inform MD and make notation in chart.Give business card with number on back
Past physical abuse (#23) National Sexual Assault Hotline at
1.800.656.HOPE (4673)


National Domestic Violence Hotline
1.800.799.SAFE (7233) 1.800.787.3224 (TTY)
Provide the local VINE Program (Offender Release Info.)

Give business card with number on back
Past sexual abuse (#24) National Sexual Assault Hotline at
1.800.656.HOPE (4673)


National Domestic Violence Hotline
1.800.799.SAFE (7233) 1.800.787.3224 (TTY)

Give business card with number on back

*Call Hospital/Clinic Security only if patient or staff is in immediate danger.

*Call local police only if patient wants to report abuse.

*When giving brochures, ascertain that possession will not jeopardize client safety. 


Safety Planning

During an explosive incident:

*If an argument seems unavoidable, try to be in a room with access to an exit.  Try to stay away from the bathroom, kitchen, bedroom, or anywhere weapons are readily available.

*Practice how to get out of your home safely.  Identify which routes would be best.

*Have a bag packed and ready.  Keep it at a relative or friend’s house in order to leave quickly.

* Identify one or more neighbors you can tell about the violence and ask that they call the police if they hear a disturbance coming from your house.

* Devise a codeword to use with your children, family and friends when you need to call the police.

* Decide and plan for where you will go if you have to leave home (even if you think you won’t have to).

* Use your instincts and judgment.  If the situation is very dangerous, consider giving the person you fear what they want to calm them down.  You have the right to protect yourself until you are out of danger.

*Remember, You don’t deserve to be hit or threatened!

If you have a Protective Order

*Keep the protective order on your person at all times.  Give a copy to a trusted friend, neighbor, or family member.  Be sure to give a copy to your children’s school if necessary.

* Cal the police if the person you filed the order against breaks the protective order.

* Inform employers, family, friends, neighbors, and your family physician that you have a protective order in effect.

Preparing to Leave

*Open a savings account and/or credit card in your own name to establish your own independence.  Remember to change passwords and restrict access.

* Get your own post office box.  You can then privately receive checks and letters to become more independent.

* Leave money, and extra set of keys, copies of important documents, extra medicines, and clothes with someone you trust or in a safe place so you can leave quickly.

* Determine who would be able to let you stay with them or lend you some money.

* Keep the shelter hotline phone number close at hand for emergencies, or better yet, memorize the number.

* Consider alternate plans for pet care

* Review your safety plan as often as possible in order to plan the safest way to leave.

Remember: Often victims of Domestic Violence are in the most danger when they leave an abusive situation

Safety and Electronic Devices

Electronic devices including computers, cell phones, land phones, etc. can be used to monitor your behavior and even stalk your whereabouts.  Be aware of the information that can be retrieved using caller ID, redial, phone and computer histories.

Cars and cell phones often have GPS (Global Positioning Systems) that can be used to track your current location and where you have been.

Public domain computers at the library or coffee houses are good alternatives when trying to avoid having communication traced.

Safety at Home and Work

*Change locks on doors as soon as possible.  Be sure to secure windows.

*Schedule an appointment with a safety planner from the Sheriff’s Department to come to your home.

*Discuss a safety plan with your children so they know how to access help when needed.

*Inform your children’s daycare, school, bus driver, etc. about who has permission to pick up your children.

*Inform neighbors and landlords that they should call the police if they see your abuser around your home.

*Inform appropriate resources at work such as office or building security of the situation.  Provide them with a picture if possible.

*Screen calls whenever possible.

*Have a safety plan when you leave work.  Have security escort you to your car and wait until you are safely on your way.  Use a variety of routes to avoid predictability.



What to take when you leave:


  • Driver’s license
  • Children’s birth certificates
  • Your birth certificate
  • Social Security cards
  • Welfare Identification


  • Money and/or credit cards
  • Bankbooks
  • Checkbooks

Legal Papers

  • PROTECTIVE ORDER – keep it with you at all times
  • Lease, rental agreement, house deed
  • Car title, registration and insurance papers
  • Health and life insurance papers
  • Medical records for you and children
  • School records
  • Work permits/Green cards/VISA
  • Passport
  • Divorce and Custody papers, marriage license
  • Pre-trial bond release papers


  • House and car keys
  • Medications
  • Jewelry
  • Address Book
  • Pictures of you, children, and the abuser
  • Children’s small toys
  • Toiletries/Diapers
  • Change of clothes for you and the kids
  • Social security numbers for all family members