Summary of "A family planning clinic-based intervention to address reproductive coercion: A cluster randomized controlled trial," Miller et al., Contraception, February 2016.
"Adolescent and young adult women seeking care in family planning (FP) clinics report higher rates of intimate partner violence (IPV) compared to their same-age peers, likely related to [the] impact of IPV on unintended pregnancy and poor sexual health," according to Elizabeth Miller of the University of Pittsburgh's School of Medicine and colleagues.
According to the researchers, "Reproductive coercion (RC), including pressuring partners to get pregnant and direct interference with contraception, is a prevalent mechanism linking partner abuse and unintended pregnancy."
The researchers noted that while "[s]creening for IPV in health care as routine practice has been recommended since the 1990s," screening patients without also providing intervention "appears to be ineffective." They wrote, "Given the prevalence of IPV/RC among women seeking reproductive health services and barriers to disclosure, shifting the health sector response from screening and disclosure to universal education and brief counseling about the impact of IPV on health with all patients may serve as primary prevention (for those never exposed), secondary prevention (for individuals with histories of IPV) and intervention for those experiencing IPV (including individuals who do not disclose)."
The researchers pointed to an FP provider-delivered intervention, called Addressing Reproductive Coercion in Health Settings (ARCHES), which "blends (1) universal education and assessment regarding IPV/RC, (2) harm reduction counseling, and (3) supported referrals to victim services (offered to all clients regardless of disclosure)."
According to the researchers, an initial randomized trial showed that "ARCHES reduced the odds of recent pregnancy coercion (a component of RC) at 4-month follow up by 71% compared to standard of care." In the latest study, the researchers conducted a "cluster randomized controlled trial, scaled to reach more clinics and women, ... to assess short-and longer-term (12 month) effects of [the ARCHES] intervention on knowledge and harm reduction and, in turn, on RC, IPV and unintended pregnancy among adolescent and young adult women." The researchers also "conducted subgroup analyses of women recently exposed" to RC or IPV, based on the hypothesis that the ARCHES intervention would be most relevant for such women.
Methods
For the study, researchers recruited women ages 16 to 29 who were seeking care at "25 FP clinics (17 clusters) in western Pennsylvania" between October 2011 and November 2012.
Eleven of the clinics were put in the intervention category, while the remaining 14 clinics were the control group. The staff at intervention clinics received ARCHES training, which encouraged universal discussion of IPV and RC issues with clients and instructed them to distribute brochures with relevant educational information to all clients. Staff also were trained to provide additional counseling to women who disclosed RC or IPV, including "counseling to reduce risk of partner interference with contraception and increase safety." The control clinics continued to provide care as usual.
Study participants were surveyed at the initial clinic visit (baseline), 12-20 weeks later (T2) and 12 months later (T3). According to the researchers, the surveys assessed demographic information and included questions related to the study's primary outcomes -- exposure to IPV and RC -- as well as secondary outcomes, including unintended pregnancy, the recognition of RC or IPV, participants' confidence in implementing harm reduction behaviors, the use of such behaviors and awareness of IPV-related resources. In addition, women who disclosed experiencing RC or IPV within the past three months at baseline were asked at T2 and T3 about their use of IPV resources. Such women also were asked at T3 whether they had disclosed their exposure to IPV or RC to a health care provider.
Results
The study included 4,009 women, of whom 3,687 (92 percent) completed the baseline interview, 3,017 (82 percent) completed the T2 survey and 2,926 (79 percent) completed the T3 survey. Most of the participants were 24 years old or younger (73 percent) and white (80 percent).
The researchers found, at baseline, 11.4 percent of study participants reported an unintended pregnancy within the last year, 11 percent reported experiencing IPV within the last three months and 5.1 percent reported experiencing RC within the last three months. According to the researchers, participants who did not complete the follow-up surveys tended to be younger and more likely to have reported experiencing IPV at baseline than those who completed the T2 and T3 surveys. Respondents who did not complete the T3 survey also were more likely to have reported experiencing RC at baseline. Rates of participant attrition did not differ between control clinics and intervention clinics.
According to the researchers, "Intervention effects for the entire sample were not significant for RC or IPV." Further, they did not find any "differences in past year unintended pregnancy between groups at T3 (14.4% vs. 12.5%)." They noted that the use of long-acting reversible contraception (LARC) was similar between the intervention and control groups both at baseline (5 percent) and at T3 (8 percent).
However, the researchers found that participants' "[s]elf-efficacy to implement harm reduction behaviors increased in the intervention arm compared to controls." Moreover, by T2, participants at the intervention clinics showed "greater increases in knowledge of IPV resources" and by T3, "intervention participants were more likely to know about the national domestic violence hotline (93% vs. 87% ...), more likely to have called the hotline (1.4% vs. 0.8% …) and more likely to have shared the [hotline] number with someone else (9.5% vs. 4.8% ...)."
The researchers noted, "Among those reporting recent IPV or RC at baseline, intervention effects for RC and IPV were not significant, and significant for knowledge of IPV resources." Overall, "[t]here were no differences in use of IPV-related resources or disclosure to a health care provider."
According to the researchers, "'as-treated' intervention effects ... among the entire sample showed greater increased self-efficacy and knowledge of IPV resources with implementation of the intervention as intended." The study also found that "a higher baseline RC score was associated with greater reduction in RC from the intervention at T3." Moreover, "[t]he 'as-treated' analyses found even greater reductions in RC at T3 for both the entire sample ... and those with baseline exposure to IPV or RC."
Discussion
The researchers found that while "the [ARCHES] intervention did not influence recent IPV, RC or unintended pregnancy among this sample of FP clients," it did "increase[e] awareness of IPV-related resources and self-efficacy to use harm reduction behaviors." They wrote, "Women reporting more forms of RC at baseline experienced reductions in RC at 1-year follow-up based on receipt of this brief intervention, with effects strongest among those women reporting the highest levels of RC at baseline."
The researchers noted that while the study "did not find reductions in IPV or RC among the [overall] sample," the "intervention effects on self-efficacy to enact harm reduction behaviors and increases in knowledge of IPV resources for all women are encouraging" because research shows that women experiencing IPV "highly value providers offering IPV information, resources, and support regardless of IPV disclosure." They wrote, "Although many women may not identify themselves as victims of IPV or RC, incremental increases in self-efficacy to increase personal safety appear to be salient for women exposed to or at risk for such abuse."
Regarding the study's findings on the significant decrease in RC exposure among women who reported multiple forms of RC at baseline, the researchers noted the study was the first to "asses[s] an intervention targeting RC to evaluate longer-term intervention effects on women's reproductive health." They wrote that the research expands on the first study's findings and "suggest[s] relevance of this intervention for this subsample of women previously shown to be at elevated risk for unintended pregnancy."
However, "[d]espite these reductions in RC, [the study] did not find differences in reduction in unintended pregnancy between control and intervention arms," the researchers wrote, noting that such findings could have been affected by the lower-than-anticipated prevalence of unintended pregnancy at baseline or by "the rapidly increasing availability of [LARC]." They noted, "While LARC use is a harm reduction strategy to address the impact of RC, the concurrent practice changes in some control clinics preclude drawing conclusions about intervention effects on LARC use and unintended pregnancy during the course of the study."
The researchers also cited "limited implementation" as another challenge in scaling up the intervention, noting that "[o]nly two-thirds of clients at intervention sites reported having a conversation with a provider about relationships." The researchers suggested ways to address this challenge, including clinic-level changes, technology aimed at facilitating delivery and "structural changes in practice."
The researchers concluded, "[T]his trial provides evidence of potential benefits of a brief universal education and counseling intervention in FP clinics to address RC among women affected by these abusive behaviors, including helping young women increase their ability to reduce RC-related harms and increase safety."
