As health care legislation continues to face challenges in Washington, medical reform is on everyone’s mind. After years of debate, the statistics are well-known: the USA, despite spending nearly $2.5 trillion on health care in 2009, a higher portion of its gross domestic product than any other country, ranks only 37th out of 191 countries in overall health care. In fact, the only place that we take #1 in terms of health care is spending per capita; we are 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy.
Whether or not you believe in “universal” health care, we all have a stake in wanting these numbers to change. Stronger efforts to screen for and address domestic violence in hospitals could provide an unlikely solution, ultimately saving billions of dollars along with lives.
Take infant mortality, for example.
As reported by e! Science News, the United States currently ranks 27th out of 33 developed countries for life expectancy at birth. Domestic violence (dv) has been identified as a major barrier to fetal health in the recently released government health plan, Healthy People 2020, following studies showing that two of the leading causes of infant mortality, namely complications related to pre-term birth or low birth weight-outcomes, are linked with domestic violence. In fact, many adverse pregnancy outcomes, including maternal mortality and infant mortality, are significantly more likely among abused than nonabused mothers. For example, Seattle residents who reported a domestic violence incident to the police during pregnancy were significantly more likely than their peers to have a low birth weight infant, a very low birth weight infant, a preterm birth, a very preterm birth, and a neonatal death.
Furthermore, as the authors of the second study point out, this likely dramatically underestimates the health cost of intimate partner violence (IPV) during pregnancy, since women who were being abused but didn’t report the abuse to the police would have been accidentally included in the non-abused comparison group. The Center for Disease Control reports that three out of four victims don’t report abuse. These rates may go up during pregnancy, when the financial, emotional, and quality of life cost to the victim of leaving is greater. Abusers utilize domestic violence as a means of excerising control, and because pregnant women are trapped in the relationship as well as increasingly focused on the changes they are undergoing, it is unsurprising that victimization studies find that pregnancy is a particularly dangerous time for victims of abuse. Abuse often begins or escalates during pregnancy, and pregnant women are three times more likely to be killed by an intimate partner than their peers who are not pregnant. In fact, homicide is the leading cause of death for pregnant women.
DV is more common than other recognized obstetric complications such as pre-eclampsia, placenta praevia, or gestational diabetes, for which women are routinely screened. The March of Dimes, a politically neutral public health organization that provides information to expectant mothers, reports that 1 in 6 pregnant woman suffer from domestic violence during pregnancy. This increased likelihood of abuse comes at a time of particular vulnerability; both physical and psychological abuse can have massively detrimental effects to mother and child. Physical attacks on pregnant women often center around the stomach area, causing direct injury to the fetus. Psychological abuse causing stress, fear and anxiety during pregnancy is associated with increased pre-term birth, lower birth weight and emotional and mental problems in children. Dv is also associated with alcohol and drug dependence, suicide attempts, depression and post traumatic stress disorder, the effects of which harm both the mother and her future child. Reproductive abuse is also a factor; victims of abuse are significantly less likely to receive adequate prenatal care, and 40% of abuse victims report that their pregnancy is unwanted, as opposed to 8% of the general population.
Screening pregnant women for domestic violence and providing more support for victims during pregnancy are important steps that we must take to ensure the health of women and their future children. Although effective screening for dv is still worryingly infrequent, 70-80% of victims of abuse say that they would like their provider to talk to them about abuse. And there are promising new developments on the horizon; new screening tools such as the one developed by Planned Parenthood of New York capture far more accurately the actual prevalence of dv, and have been utilized to connect expectant mothers with services more effectively.
Stopping Violence in the Next Generation
Ensuring that pregnant women are aware of their resources when it comes to intimate partner violence is particularly necessary because children born into households in which the woman is abused are significantly more likely to be abused themselves. About 50% of men who abuse their wives also abuse their children. Furthermore, merely witnessing domestic violence is so psychologically damaging to a child that it is considered child abuse. In these situations, recognizing that both mother and child are victims—rather than merely removing the child—is crucial to creating a healthier future. Children who grow up in households in which there is any kind of abuse are significantly more likely than their peers to be depressed, anxious, suicidal, truant, and have conduct and physical health problems.
They are also significantly more likely to be abusers themselves; growing up in a household in which abuse occurs is the single greatest risk factor for being abusive yourself; a boy’s likelihood of being an abuser jumps 157%.
Which, of course, only perpetuates the cycle, preserving it for the next generation and helping to explain why rates of abuse are epidemic in some communities. Even if you escape abuse in your own life, domestic violence is truly everybody’s problem; supporting efforts to intervene may protect your daughters and sons down the road.
But What Are The Actual Numbers?
Pregnant women are a unique group who are particularly likely to be abused, and who face particularly detrimental effects from abuse. But is the overall cost to the medical system of abuse really that large? Do that many victims seek emergency services?
The US Department of Justice finds that 37% of women admitted to emergency rooms for care for violence-related injuries were injured by a current or former intimate partner. At the same time, however, the CDC reports that only about 4% of women admitted to the emergency room were admitted for injury resulting from violence; accidental falls, for example, or illness claim much larger numbers.
Even this seemingly fractional percentage, of course, is extremely costly to the health system. In 2003, the CDC, examining costs from the 700,000 reported incidents of domestic violence in America in 2001 (all included in the 1/3 of 4% violent victimizations), placed the annual estimated direct health care cost associated with domestic violence at around $4.8 billion.
Yet these numbers dramatically underestimate the cost of abuse to our health care system. A recent University of Pennsylvania study found that although about 80% of domestic violence victims who report incidents to the police seek health care in emergency rooms, nearly three out of four are never identified as victims of abuse during any hospital visit. This is despite the fact that most sought ED care frequently; an average of 7-8 times each in the four year study period.
How it is possible that so many victims of severe abuse slipped through the cracks? One reason: 78% of the visits were for medical complaints other than injuries associated with abuse. In fact, assault was the main documented cause in only 3.8% of the victims’ ED visits.
Clearly, by focusing only on when IPV is disclosed, the CDC misses a massive amount of harm.
Finally, even the numbers found in the University of Pennsylvania study are a conservative estimate because they describe only women who were harmed enough—and willing enough—to go to the police. As a group, then, these women were particularly likely to be flagged as dv victims, yet the study found that only 28% were ever identified. And even in the cases in which they were identified as victims of abuse, fewer than 35% of ERs made any documented assessment of whether they had a safe place to go after discharge, and they were referred to services only 25% of the time. Considering that these statistics are limited to a group of particularly brutalized victims who are trying to seek help, it’s certain that many more victims are being overlooked, their injuries not recorded because they result from secondhand effects of dv or are disguised in other categories such as that old cliché, “accidental falls.”
Is it possible that victims of abuse are just particularly unlucky?
Of course, an alert reader could identify a problem in the statistics above; perhaps the 78% of medical problems not categorized as abuse-related really weren’t abuse-related. Could it be just normal that victims of abuse visit the emergency room an average of 7-8x in four years? (How frequently do women in non-abusive relationships visit the emergency rooms?)
The answer is: a lot less frequently. Over a 3-year study period, health care costs for women who disclosed a history of physical, sexual, and/or emotional abuse were on average $1,700 higher than those of their cohorts who had never been abused. In short, being a victim of any kind of abuse—note the inclusion of “emotional abuse”—results in higher health care costs. These findings, by the way, are neither unique to the study nor confined to a small number of victims experiencing exceptionally terrible harm. A 2007 longitudinal cohort study of over 3000 female patients found that 44% of the sample reported a history of IPV. These women had significantly higher healthcare utilization and costs both during and after the abuse than women who had never been abused. And although medical costs decreased over time after the IPV ceased, healthcare utilization for previously abused women was still 20% higher 5 years after their abuse had ended. Ultimately, the excess costs due to IPV were estimated to be $19.3 million per year for every 100,000 female enrollees aged 18-64. The study concluded that IPV has a major impact on medical care resource utilization and that preventative efforts should be taken.
And yes, you read that right: the health care costs of domestic violence don’t stop after the violence ends. In fact, they may even go up. Another study involving 2,026 women patients found that although abuse victims’ health care costs average $585 per year higher than normal during the period of abuse, their health care costs rise to more than $1,200/yr above non-abused women for the first two years after abuse, and $444 after the third year. One explanation for the continuing increase in cost is that women may still be exposed to abuse after the conclusion of the relationship; as we’ve reported before, a significant amount of IPV harm takes place after partners separate. It’s also possible that women are not able to access the health care services that they should be receiving when they are with a controlling or abusive partner. And once again, the study’s findings are conservative, because it did not distinguish between severity or type of abuse and because some victims participating in the study may not have admitted to being abused and so were not included among the abuse victims. Ultimately, the researchers stressed the importance of screening and prevention efforts: “Victims of abuse require more health care resources for years after their abuse ends. If we can prevent domestic violence, we are not only helping the women involved, we are also saving money in our health care system.”
As mentioned before, none of this harm is included in current cost estimates of domestic violence, which already amount to billions of dollars, even in 2003 dollars unadjusted for inflation.
And the costs keep coming; abuse is already linked to depression, anxiety, substance abuse, and suicide attempts, and negative physical health consequences including migraines, asthma, chronic pain, arthritis. New research suggests that it is a major risk factor for heart disease and that children in abusive households are at greater risk for cancer later in life. That’s right: cancer.
The surprise with which you’re likely reading that is only evidence of the way that the massive cost of IPV has been is still being uncovered, after too many years of silence.
The Bright Side
Yet despite the still epidemic prevalence of abuse, domestic abuse is a solvable public health problem. In 2006, the Justice Department reported that intimate partner violence rates had fallen by more than 50% between 1993 and 2004. Among some segments of the population, namely males and black females, intimate partner homicides have fallen sharply as well. The number of services for victims, mostly due to funding from VAWA, have skyrocketed since 1994. In an increasingly computerized age, steps to screen victims for abuse can and should be taken, and community support systems equipped to communicate effectively with hospitals. Hospital workers must develop and learn protocols to better serve victims of abuse. And the systems already in place in hospitals must be refined; as the UPenn study shows, current screening procedures are worryingly ineffective—particularly for victims who may not identify as victims—and women who are being abused must be given information about support services. Ultimately, there are many steps that are within our power that we can take to reduce domestic violence.
Emphatically, they are steps worth taking.
Further citations provided upon request