Interventions for intimate partner violence during the perinatal period: a scoping review protocol

Abstract

Introduction

Globally, the prevalence and incidence of perinatal intimate partner violence (IPV) are well documented and substantiated; however, there is an urgent need to identify interventions to prevent recurrence or revictimisation, and decrease the harms of perinatal IPV. This scoping review is designed to broadly capture all potential interventions for the secondary prevention of IPV, review them in detail, and assess what can reduce revictimisation and foster improvements in both maternal and neonatal outcomes.

Methods and analysis

With the structure of the Joanna Briggs Institute and Arksey and O’Malley methodology for scoping reviews, the search will be conducted in: MEDLINE(R) ALL (OvidSP), Embase (OvidSP), CINAHL (EBSCOHost), APA PsycInfo (OvidSP), Cochrane Central Register of Controlled Trials (OvidSP), Web of Science, and Applied Social Sciences Index & Abstracts (ProQuest). A manual search of the reference lists of the retrieved articles will be conducted to capture all relevant studies for potential inclusion. A year limit of January 2000–June 2022 will be applied to retrieve most current peer-reviewed articles. No search filters or language limits will be used, but only publications in English and French will be eligible for inclusion. Interventions include but are not limited to: psychotherapy, educational sessions, home visitation, etc. Outcomes include but are not limited to: (1) harms of IPV among survivors (eg, revictimisation) and (2) adverse perinatal outcomes (eg, preterm birth). Interventions will be excluded if they target the perpetrator or child(ren) alone. Titles and abstracts of included studies will be screened in duplicate. Full-text documents will be extracted and reviewed by two independent reviewers. Conflicts between reviewers will be resolved by a third independent reviewer. Findings will be presented with descriptive statistics and narrative synthesis.

Ethics and dissemination

Ethics approval is not required for this scoping review. The results will be disseminated through peer-reviewed publication and conference presentations.

Study registration

Open Science Framework (OSF) registry (https://osf.io/e294r) in Centre for Open Science (OSF) on 27 May 2022.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This review will examine the multidisciplinary literature from nursing, medicine, sociology and psychology to identify any intervention pertaining to perinatal intimate partner violence (IPV).

• Due to the high degree of heterogeneity among studies examining interventions for perinatal IPV, the scoping review methodology is better suited to map and present findings compared with a systematic review or meta-analysis.

• Patient partner/peer researchers and an expert working group will provide feedback on the clinical relevance and feasibility for each of the reported interventions.

• Due to the nature of a scoping review, a quality assessment will not be conducted.

• This scoping review will include literature published in English or French, so some relevant publications in other languages may be missed.

Introduction

Gender-based violence and intimate partner violence (IPV) are human rights violations contributing to several adverse social and health outcomes as stated by the WHO.¹ IPV broadly includes any physical, sexual and psychological violence and abuse, including threats of aggression, coercive control, and stalking from a current or former partner.² While IPV can affect all genders, a disproportionate amount of IPV occurs against women (trans inclusive).³ It is estimated that one in three women globally will experience IPV in their lifetime.⁴ The stress brought upon by the global COVID-19 pandemic, including job loss or reduced household income, housing instability and increased substance use have increased risks of IPV,^5–8 with growing evidence that this is affecting those in the perinatal period.⁵

The perinatal period encompasses 12 months preconception, during pregnancy and 12 months after birth, or post partum.⁹ In Canada, the prevalence of IPV during pregnancy alone is estimated to be between 6% and 10.5%¹⁰; however, these are often underestimates. Since the COVID-19 pandemic began in March 2020, the prevalence of IPV across the perinatal timespan has been estimated to be as high as 24%.^{5 11} Perinatal IPV is associated with many adverse obstetrical and neonatal health outcomes including low birth weight, intrauterine growth restriction, preterm birth, postpartum depression and termination of pregnancy.¹² In extreme cases, it can lead to maternal homicide as reported by the Canadian Femicide Observatory for Justice and Accountability.¹³

Universal screening for IPV can increase the chances of identifying someone experiencing IPV; however, without adequate follow-up and effective interventions, universal screening for IPV is not recommended by the WHO guidelines, and in some cases is considered unethical.¹⁴ Screening of individuals has to result in improved health status of those screened, and there are several studies that have shown that screening alone is not sufficient to reduce harms.^15–17 Risk factor-based screening is recommended and involves identifying those at increased risk of violence, including a history of IPV, substance use, mental health issues, low socioeconomic status or younger age.¹⁸ A Cochrane systematic review found that screening in the antenatal healthcare settings increases the chance of identifying individuals experiencing IPV, but clearly states that screening must be followed by actual interventions to improve outcomes.^{19 20}

Several studies have identified the challenges and lack of training for healthcare providers to respond to the needs of survivors of IPV or those at risk of IPV.^{12 20–24} Equipping healthcare providers with evidence and knowledge of effective (and non-effective) interventions for perinatal IPV can increase provider competency and comfort to respond to the signs of IPV. Moreover, identifying effective IPV interventions can inform future policymaking, best practices and protocol implementation across regional healthcare systems. As pregnancy is a unique time when individuals are highly engaged with the healthcare system for prenatal check-ups, labour and delivery, and postpartum follow-up, there are more frequent opportunities to intervene with survivors of IPV.²⁵

Currently, there are five systematic reviews examining interventions for IPV during pregnancy, reviewing studies published between 2000 and 2021, which included a total of 23 unique interventions.^{9 26–29} Three reviews are restricted to pregnancy and two reviews investigate the perinatal time frame more broadly. The reviews published by Daley et al, Jahanfar et al, Van Parys et al and O’Reilly et al concluded that there were mixed or inconclusive findings, weak effect sizes and limited quality of evidence on the efficacy of interventions for reducing revictimisation and improving physical and mental health for survivors. Reyes et al included 13 unique studies specifically examining advocacy and counselling interventions for perinatal IPV, concluding that interventions with ongoing support produce the greatest clinical benefit. None of the reviews included detailed information on the interventions, but primarily focused on the effect size of the different kinds of interventions or restricted the interventions to randomised controlled trials (RCTs).^{9 26} These restrictions are beneficial when comparing studies or evaluating quality of evidence but will likely exclude innovative interventions without the resources to run RCTs. This also limits information on the details of the interventions, which is critical for comparisons and evaluation. For example, a counselling intervention could range from a one-time session (which may not be sufficient) to several sessions (which may be sufficient to effect change). Two thematic reviews have been written on interventions for IPV in the general (non-perinatal) population by Rivas et al, which included 10 unique studies on advocacy interventions, and by Adams et al, which included 26 qualitative studies for nurse home visitation. Both thematic reviews did not include studies from the perinatal setting.^{30 31}

There is need for a review to cover the entire perinatal timespan and include a wide range of study designs (quantitative, qualitative and mixed-methods studies) and intervention types (eg, psychotherapy, educational sessions, safety planning, advocacy, etc), across a wide range of disciplines (eg, nursing, medicine, sociology, psychology). Additionally, given the rapid shift to virtual platforms during the COVID-19 pandemic, it is possible that there are emerging innovation interventions yet to be evaluated.^{32 33}

Objectives

This scoping review is designed to explore multiple disciplines to broadly identify any interventions for perinatal IPV. The goal of this scoping review is to ultimately inform the development of a trial to evaluate the effectiveness of an intervention for perinatal IPV that can be administered from perinatal settings. The objectives of the scoping review are to:

1. Identify and describe the range and core components of existing interventions that have been used to support survivors exposed to IPV during the perinatal period.

2. Describe the core components of the interventions and investigate the measured outcomes including:

   1. Perinatal IPV, including revictimisation and ongoing abuse.

   2. Adverse obstetrical and neonatal outcomes.

3. Identify knowledge gaps in the literature evaluating interventions for perinatal IPV.

Methods and analysis

Protocol registration and reporting

This protocol was developed with adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines (online supplemental appendix 1), as well as the Joanna Briggs Institute and Arksey and O’Malley’s methodology for scoping reviews.^34–36 This study protocol was prospectively published on Open Science Framework (OSF) registry (https://osf.io/e294r) in Centre for Open Science (OSF) on 27 May 2022.

Patient and public involvement

Our patient partner and peer researcher (MAOG) is involved in the conceptualisation and design of this protocol. She is a member of the OMNI Patient Partner Program³⁷ and helps to advance patient and family-oriented research by sharing perspectives that improve the quality and relevance of our work.

Expert working group

This study includes an expert working group including specialists in perinatal care and sexual and gender-based violence. All included studies will be reviewed to assess feasibility and relevance to the perinatal care environment. The engagement of the expert clinical working group is designed to be flexible and evolve over time. Possible options for the process include a presentation of the findings of the scoping review, collecting initial impressions from the providers and partners on the different types of interventions (eg, counselling, education, etc). Possible next steps include developing a tool with clear criteria for evaluating feasibility (eg, resource availability, staff training requirements, patient acceptance, etc) and clinical relevance, namely that the intervention would impact clinical outcomes (eg, preterm birth, violence-related revictimisation).

Search strategy

Search strategies will be developed by an information specialist (KF) and peer reviewed using the Peer Review of Electronic Search Strategies guideline.³⁸ The search will be conducted in: MEDLINE(R) ALL (OvidSP), Embase (OvidSP), CINAHL (EBSCOHost), APA PsycInfo (OvidSP), Cochrane Central Register of Controlled Trials (OvidSP), Web of Science, and Applied Social Sciences Index & Abstracts (ProQuest). Each database will be search for the concept of “perinatal” and “IPV” using a combination of subject headings and keywords. Drafting the search strategy was informed by two Cochrane reviews for the concept of IPV,^{26 39} and by consulting the search method from the Cochrane Pregnancy and Childbirth’s Trials Register⁴⁰ for the concept of perinatal. No search filters or language limits will be used; however, only English and French articles will be included. We restricted the search from 1 January 2000 to 1 June 2022 to allow for a relatively recent and comprehensive coverage of the literature. It may provide a more timely and relevant picture of the current state of knowledge; however, it may limit information on longer-term outcomes. This also fits within our budget and human resources available for this review.

Non-peer-reviewed articles (eg, commentaries, editorials, conference abstracts) will be removed. The keywords and search strategy are included in table 1. The full search strategy for all databases is included in online supplemental appendix 2. Databases in multiple disciplines across fields of nursing, medicine, sociology and psychology were chosen to capture as many possible studies examining any interventions for perinatal IPV, as violence is an intersectional issue studied in many disciplines.⁴¹ A manual search of the reference lists of the retrieved articles will be conducted to capture all relevant studies for potential inclusion. To account for grey literature, the register of clinical trials (ClinicalTrials.gov) and preprint servers (MedRxiv) will also be searched.^{42 43}

Table 1.

Keywords for search strategy

Key concept	Keyword
IPV	Intimate partner violence, domestic viol*, domestic abuse, Gender based violence, IPV, spouse abuse, battered women, relation* or interperson* abus* or violen*,
Population	Perinatal, pregnan*, obstetric, post-partum, pre-partum, maternal, child-bearing, prepregnancy, postpregnancy, preconception*, postconception*, peri-conception*, pre-birth*, post-birth*

*=wildcard.

IPV, intimate partner violence.

Eligibility criteria

Study design

All peer-reviewed studies reporting primary data describing IPV interventions with the perinatal population will be included in this scoping review. Only English and French literature will be included for review, regardless of country of origin. Exclusion criteria: non-peer-reviewed articles (eg, editorials, comments, letters and conference abstracts); interventions on IPV screening alone; and secondary analyses or reports (the primary study will be identified and included if appropriate).

Population

The primary eligible population includes female individuals in the perinatal period (12 months preconception, pregnant, 12 months post partum) and currently experiencing IPV. Individuals of all sexual and gender identity will be included. Population characteristics and details regarding the process of identifying IPV cases can be found in the data extraction form (online supplemental appendix 3). Details on the training for the intervention will be described in detail. Eligible interventions include those for the survivor experiencing perinatal IPV, or the survivor and perpetrator (eg, couples therapy) or child (eg, family therapy). Exclusion criteria: interventions that target the perpetrator or child(ren) alone.

Concept

Perinatal IPV interventions may take place either at a healthcare setting or within the community. Adverse perinatal, obstetrical and neonatal outcomes will be identified. The anticipated health outcomes are listed in table 2. Common types of interventions include, but are not limited to: psychotherapy, couples counselling, family therapy and educational sessions.^{33 44–46} Common modes of delivery include, but are not limited to: in-person, online, in-clinic, home visitation, etc. Detailed characteristics of the interventions will be extracted and reported, as shown in the data extraction form in online supplemental appendix 3. This scoping review will include studies that compare an intervention group with a comparison group. The comparison group may range from no intervention to usual care.^{47 48} Exclusion criteria: interventions that are equivalent to the standard or usual care, such as resource pamphlets and standard follow-up appointments.

Table 2.

Outcomes pertaining to direct harms of intimate partner violence (IPV)

Outcomes	Definition	Measurement tool
(1) Revictimisation
Revictimisation of IPV	Any recurring: Physical violence—fractures, contusion, burns, dental injuries, etc Sexual violence—any unwanted Psychological harm Coercive control Stalking noted by a patient’s current or former partner Reproductive coercion Other	Self-reported (ie, questionnaires) or clinical documentation. Tool used for screening or identification of IPV will be extracted.
(2) Maternal social and well-being outcomes
Quality of life or health-related quality of life	The subjective feeling of being able to enjoy life, based on aspects of physical, mental and social health	Self-reported questionnaires
Social functioning	The ability to function in the role one plays in their life such as work, family and other groups	Self-reported (ie, questionnaires)
(3) Maternal mental health outcomes
Depression	Mood disorder causing depressive mood or loss of interest in activities—also called major depressive disorder	Clinical diagnoses, prescriptions for mental health-associated treatment
Depressive symptoms	Symptoms of major depressive disorder, as based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria including but not limited to: low mood, low concentration, low energy, changes in appetite or sleep, fatigue, feelings of worthlessness, psychomotor slowing, decreased interest in activities, suicidal ideation	Self-reported, prescriptions for mental health-associated treatment
Postpartum depression	At least one episode of major depressive disorder in postpartum women manifesting up to 1 year after giving birth	Clinical diagnoses, prescriptions for mental health-associated treatment
Suicide attempts	Non-fatal attempt to end one’s life	Self-reported, ED visit, patient chart
Somatisation	Physical symptoms caused by a psychological disorder	Self-reported, patient chart, clinical diagnoses, prescription for mental health-associated treatment
Psychological distress	Pain, discomfort or anguish causing a state of negative emotions	Self-reported
Substance use	Use of alcohol or drugs	Self-reported, prescriptions for mental health-associated treatment
Substance use disorder	Based on the DSM-V, a pattern of disordered use of substances resulting in physical and psychological symptoms and impairments in functioning, including domains of: impaired control, social problems, risky use and physical dependence	Clinical diagnoses, prescriptions for mental health-associated treatment
Eating disorder	Disorder of the appetite and food intake causing psychological and physiological disruptions	Self-reported, clinical diagnoses, prescriptions for mental health-associated treatment
Anxiety disorder(s)	Group of mental disorders embodying distress and dysfunction in areas of social, occupational or other areas of functioning, including, but not limited to: generalised anxiety disorder, panic disorder, social phobia and other phobias	Self-reported, clinical diagnoses, prescriptions for mental health-associated treatment
Anxiety symptoms	Symptoms of anxiety, including excessive worry, difficulty controlling worries, restlessness, fatigue, difficulty concentrating, irritability, sleep disturbance and muscle tension	Self-reported, prescriptions for mental health-associated treatment

All outcomes will be extracted and are not restricted to this list.

ED, emergency department.

This scoping review will report on the following outcomes listed in tables 2 and 3: (1) IPV recurrence and associated harms among survivors and (2) adverse maternal and neonatal outcomes. IPV may be assessed in different ways, including self-report measurements such as screening questionnaires, or via clinical documentation such as hospital visits. Common maternal and neonatal outcomes include, but are not limited to: preterm birth, low birth weight, miscarriage, termination of pregnancy, maternal death, perinatal death and premature rupture of membranes.⁴⁹ Secondary maternal outcomes include psychological symptoms such as postpartum depression and symptoms of depression or anxiety.

Table 3.

Obstetrical health outcomes

Outcomes	Definition	Measurement tool
(1) Maternal obstetrical health outcomes
Miscarriage	The spontaneous loss of a fetus before week 20 of a pregnancy; also known as ‘spontaneous abortion’	Clinical documentation
Late entry into prenatal care	Prenatal care which started during the 3rd trimester (7–9 months) of pregnancy	Clinical documentation
Premature rupture of membranes	The rupture of fetal membranes (ie, amniotic sac) before labour starts, given the pregnant person is after 37 weeks of gestation	Clinical documentation of history and physical examination
Inadequate weight gain during pregnancy	Gestational weight gain less than guidelines, stratified based on pre-pregnancy BMI	Weight measurements in clinic
Hospitalisation during pregnancy	Hospital admission during the pregnancy period	Clinical documentation
History of spontaneous abortion	Any previous spontaneous abortion, as defined as the loss of pregnancy before 20 weeks of gestation	Self-report or clinical documentation
Dystocia	Difficult or slow labour progression, including abnormal or slow dilation of cervix and/or descent of fetus during labour	Clinical documentation
Gestational hypertension	Hypertension is defined as systolic blood pressure >140 mm Hg and diastolic blood pressure >90 mm Hg; hypertension during pregnancy or gestational hypertension	Blood pressure measurements and clinical documentation
Pre-eclampsia	(1) Primary onset of hypertension with proteinuria; hypertension during pregnancy is defined as systolic blood pressure >140 mm Hg and diastolic blood pressure >90 mm Hg or (2) primary onset of hypertension with end-organ damage after 20 weeks of gestation	Blood pressure measurements and clinical documentation
Vaginal bleeding during pregnancy	Any serious bleeding during pregnancy, as documented by clinician including antepartum haemorrhage, placental abruption, etc	Clinical documentation
Urinary tract infection	Infection of urinary tract, including the ureters, bladder and urethra	Clinical documentation
Unintended pregnancy	Unwanted or unintended pregnancy	Interview with participant
Unwanted abortion	Unwanted abortion or loss of a fetus before 20 weeks of pregnancy	Interview with participant
(2) Neonatal health outcomes
Perinatal death	Death of baby between 22 weeks of gestation and 7 days after birth	Clinical documentation
Stillbirth	Death of baby after 22 weeks of gestation prior or during labour/birth	Clinical documentation
Preterm birth or prematurity	Infants born before the 37th week of pregnancy	Clinical documentation
Low birth weight	Less than 2500 g birth weight	Clinical documentation of the first weight of the newborn
Small for gestational age	Newborn’s weight is lower than the 10th percentile for their sex and gestational age	Weight measurement in clinic
History of perinatal death	Any previous perinatal death, as defined by death of an infant between 22 weeks of gestation and 7 days after birth	Self-report or clinical documentation
Fetal distress	Clinical diagnosis of fetal hypoxia either before, during or after labour, clinical picture of non-reassuring fetal heart rate, fetal bradycardia, repetitive variable decelerations	Clinical documentation
Failed newborn-to-mother bonding	Clinical diagnosis of the persistent lack of emotional bond between infant and parent	Clinical documentation
Intrauterine growth restriction	Fetal weight lower than 10th percentile based on fetal age	Clinical documentation, diagnosis also based on small gestational age
Urgent Apgar score	An Apgar score of neonate, based on appearance, pulse, grimace, activity and respiration of neonate; score of <3	Clinical documentation

All outcomes will be extracted and are not restricted to this list.

Studies examining outcomes involving feasibility of intervention, satisfaction and acceptance by patient and healthcare provider will also be collected.

BMI, body mass index.

Context

Studies from all countries and people of all ethnicities or races will be included. The country where the intervention took place will be taken into account when synthesising data, as effectiveness of intervention may be attributable to differences in the healthcare systems (eg, universal healthcare vs private), socioeconomic or political characteristics.⁵⁰ Additionally, innovative interventions may be developed in lower-resource settings that have not yet been considered for implementation in high-resource settings.

Screening

Studies identified from the search will be uploaded to Covidence (Veritas Health Information, Melbourne, Australia), and titles and abstracts will be independently screened in duplicate (YF and NS).⁵¹ For screening forms, see online supplemental appendix 3. If any of the inclusion criteria are unclear based on the title/abstract, the study will be included for full-text review. Full-text screening using the same criteria will be conducted in duplicate, independently. In the case of discrepancies between reviewers in each step of screening, a third independent reviewer (KAM) will resolve the conflict. A flow diagram conceptualised from the Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram will be used to illustrate the process for study inclusion.⁵²

Data extraction

Extraction of each included document will be conducted in duplicate, independently (NS and YF). We will extract corresponding data in the following categories: (1) general information including study design, author name, author affiliation, country setting, publication year, sample size; (2) population characteristics of the target of the intervention; (3) intervention characteristics for each intervention and comparator studied such as setting of intervention (eg, community, tertiary care setting) and intervention type (including, but not limited to, counselling, education, home visitation); (4) referral process and setting; (5) outcomes (eg, adverse obstetrical health outcomes, IPV-related harms, feasibility, etc); and lastly (6) declarations involving funding, conflicts of interest and ethics approval. A full list of extracted items can be found in the data extraction form (online supplemental appendix 3). The data extraction form was developed with guidance from the Template for Intervention Description and Replication checklist.⁵² All discrepancies will be resolved through discussion among the authorship team (YF and NS) or a third independent reviewer (KAM) if a consensus is not reached. The list of items on the data extraction form is not exhaustive, as it may be updated through iterations during the ongoing scoping review process.

A risk of bias assessment will not be undertaken, as the purpose of this scoping review is to map the available evidence rather than grading the internal validity of the evidence.

Data synthesis

A narrative synthesis will be conducted following the guidance of the Economic and Social Research Council Methods Programme.⁵³ The narrative synthesis will involve assessment of types of interventions. Where possible, additional subgroup analysis for age and genders of participants will be conducted. Descriptive statistics for outcomes of studies will be presented when possible. For continuous variables, measures can include the mean, SD, median or IQR. We will use counts and proportions to describe all other data.

We anticipate that many interventions will be complex and have multiple components (eg, home visitation and safety planning). We have not predetermined how we will group the different types of interventions. As we review the identified articles, we will form groups of interventions that are similar and include a category for simple interventions focused specifically on IPV versus those that are complex and part of a programme with multiple components.

Feasibility and ease of implementation (as perceived by both the patient and healthcare provider) will be summarised in addition to the description of the intervention. At this step of the scoping review process, an expert working group comprising of healthcare professionals across multiple disciplines within perinatal care teams (eg, obstetrician/gynaecologists, nurses, social workers, IPV experts, etc) and patient partners and peer researchers will be consulted to review the clinical relevance of interventions in the perinatal care setting. The expert working group is designed to assess the feasibility of potential interventions for the obstetrical and perinatal care setting and implemented in future trials.

Ethics and dissemination

Ethics approval is not required for this scoping review. The results will be disseminated through peer-reviewed publication and conference presentations.

Ethics statements

Patient consent for publication

Not required.