AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
REBECCA WHITEMAN: So I have official PowerPoint envy. I don't know about the rest of you in here, but I don't do videos connected to my Power Point, so that was great .
And, you know, one of the things I really appreciated about your presentation in particular -- I'll be talking much more about the hands-on part. How many of you are direct service providers, how many of you see clients or supervise people who see clients? I'm going to be talking a lot of how to integrate some of the stuff around violence with those folks day-to-day in your program. And one of the questions that I've never heard anybody ask is do you know how to put your seatbelt on to the moms in your program. What a great thing to come out of that. You know, that's kind of what I do, I travel all over and I sort of look at programs all the time and I've never heard anyone ask, do you know where to put the belts on the belly and as a result of this, I definitely will. So thanks.
How many of you know who the Family Violence Prevention Fund is? A couple of you. I brought a bunch of materials, there's stuff for you to take. Please take them because I'm not bringing them back to California with me. We are a national non-profit and our web site is a huge resource for you perinatal providers and healthcare providers out there. In terms of tools and materials, we developed the National Consensus Guideline with the AMA and other national organization about how we should be talking to patients about violence in our practices, how often we should be doing that. So these are things you can get free and download off the web site. I also have pregnancy wheels here for those of you who work with pregnant moms, these are attached to your hip, aren't they? Well, this one actually reminds to you ask the question, tells you how to ask the question and tells you what to do and gives you national numbers on the back of this card for patients.
For information for you our website is endabuse.org, stopviolence.org and you can call us at 888-RX ABUSE if you have questions particular to your program. It's important that you remember that you call 888-RX ABUSE and not
800-RX ABUSE because that's an S and M call line and you pay for it. I will tell you, the last time I gave a presentation for Fee for Healthy Start, you know how you have those things you have to remember in your head and you're like, okay I'm not going to say it, I'm not going to say it. On a national web cast I said, call
1-800-RX ABUSE. I can't tell you the number of calls we got. So now it's typed up here and you all know not to call the other number and I've taken myself off the hook.
What we are going to be talking about is a project that I worked on for the last couple of years. Are you all familiar with what Healthy Start is or Healthy Start projects. Healthy Start projects are federally funded programs working with moms and their kids age 0 to 3, they are case management programs. And what I'm going to talk about in particular is how we have looked at redefining success and what does it mean to have a successful program around the kinds of family violence and how you can integrate that, how you can implement staff in the programs. So as I said, I worked on this for about a year.
Last year, I am a platinum member of American Airlines. That means I have gone through more suitcases than you probably will in your entire life unless you are another platinum frequent flier. And what's been really helpful for me in this process of going to these sites is we learned along the way how to refine this or take the best from the programs. So you'll be getting a snippet on what's the best that's out there, the true stories that come from the program that help inform us of how to change the things that we do.
You'll be able to tell the slides that are for AMCHP because they say AMCHP on them and then there are the other slides and it's important and this is another tool for you all. It's called the Public Health Tool Kit and basically what we did here is we took the best research that's out there, but we don't have your research because some of it is too knew, but it's something we will update. Take the best researches out there, synthesize it and make it into slides. So you can go back take this to your program, your department of public health, your program and say here is the information you need to know on how violence impacts kids, how violence impacts women's health, how violence impacts all these areas of health. And in addition to this in hard copy which has speaker notes that you can get off the web, there also are slides. So you're going to be seeing snippets of these throughout.
So when I go to these programs, I often sort of talk about what they may or may not already know in terms of connections between violence and the folks that they see. And for those of you who are doing direct service, how many of you ask women whether or not the pregnancy was planned? And then, isn't the slide -- doesn't the slide become interesting as you hear the answer to that. Because if you hear, no, it wasn't planned, knowing that women with unwanted or mistimed pregnancies are four times more likely to be physically hurt by their husband or partner, gives you a different take on that question. Makes you think, maybe I should be thinking about integrating my questions about violence around that piece and doing some awareness with clients around that.
dating violence and teen pregnancy. I was outed as a Planned Parenthood clinic director and a Title X clinic director before working for the Family Violence Prevention Fund and I learned about this statistic when I was still a clinic director. One of the things that came up for us as we were looking at this is we had to think about our own process around what do we do with pregnancy testing. And again, for those of you who are doing the program, somebody comes in, she's a teenager, she's nervous, what does she want? She wants the results of her test. Typically, these are tests that are done not in conjunction with a physical visit. They come in to get the results of test and then we go from there about referring them or connecting them to services. We looked at this and we said, oh, my God, we missed it. Adolescent girls who experience physical or sexual dating violence are six time more likely to become pregnant than their non-abused peers, and they're coming in for pregnancies tests and we are not asking them if they are safe in their relationships.
And so that helped us then change our internal policy and when we are working with Healthy Start sites that are working with our moms and their kids for a couple of years afterwards, they are talking to moms about birth control, they are talking to moms about what is going on in their lives, and then we are able to work with them to help them connect to the clinics that their patients go to ask them whether or not they were including this kind of information in what they do.
We know that lots of teens experience -- who are pregnant experience physical and sexual abuse during pregnancy, no surprise.
We know that women who experience abuse around the time of pregnancy are more likely to drink, use drugs, feel depressed, attempt suicide, all things that folks care about in their programs when they are managing moms.
One of the things that was interesting about this slide and working with programs is for those of you who are doing this work, is it frustrating when moms continue to drink or smoke or use drugs while she's in your program even though you've given her all the information? Really frustrating. Does it feel like she's selfish, she doesn't care, how can she be so insensitive to not love her baby. And what happens, I think, when we can kind of put a different face on why people might be self medicating, why they might be using drugs, using alcohol to sort of manage their lives, when we think about that piece around violence, we are able to do a different spin around what that intervention looks like. So a mom that I worked with who was a three pack a day smoker and had been in a very violent relationship for a very long time and this was pregnancy number three for her. She had gotten information on Kick the Butts, we had given her information to help with tips around smoking cessation, rearrange the furniture and all of that stuff, and finally we started asking her did she think there was any connection between this long term violent relationship and her connection with smoking and she said absolutely. But the one thing in her relationship with this horribly violent partner she could control was smoking. She had to ask permission to use the car, to use the phone, to go to the store, to pick her other kids up from daycare, but she could smoke whenever she wanted to. Then you're able to look at that relationship with cigarettes as a friendship, as a support of something else, and we are able to strategize differently about how to help that client with that.
We know that abused women are twice as likely as not abused women to start prenatal care in the third trimester. So again those moms who are coming in late into care, those are folks we are going to spend extra time talking to them about what's going on in their personal life.
Domestic violence related to breastfeeding. My colleague Linda Chamberlain who I love, I don't know if any of you have had a chance to hear her speak. She doesn't have kids. She's happy to tell people that all the time. She has 14 huskies instead and she's a dog musher. She was the person that actually compiled this public health tool kit. And this slide came out of both the study and also a study she did out of the state of Alaska. She's an epidemiologist, and she was asked to figure out why moms weren't breastfeeding in Alaska. So she wasn't coming at this issue from violence perspective, she was coming at the issue of how come they are not breastfeeding. And what she was able to determine, number one reason when she talked to the moms about breastfeeding was domestic violence. How come? How come?
UNIDENTIFIED SPEAKER: (Inaudible.)
REBECCA WHITEMAN: … absolutely. Another reason? Maybe related to avoiding injuries. Is it faster to move a baby away if you've got a bottle in it's mouth to move it to the side or if it's attached to you? So that was another piece she was able to determine in talking to moms and it was absolutely both of those issues.
So then when we look at programs and the focus is, you know, breastfeeding, we want all our moms to breastfeed, encouraging them to think outside the box around why she might not be has proven to be very helpful in these programs that work very closely with WIC and lactation consultants.
Rapid repeat pregnancy. So we know that teenagers who experience physical or sexual abuse are three times more likely to have a rapid repeat baby within 12 months, so you have one baby and then you have another. Are these folks who are unaware that birth control is out there and how to get it and how to use it? No. And that's something else that we are going to talk about later on that we learned in the project. But, you know absolutely, there are other pieces going on here. And I think this is one of the statistics that tends to grab people and is a new piece for folks. Is this new information for folks in the audience? Or is this sort of a known piece?
What do we talk about usually when we talk about violence with our clients? What aspect of violence are we talking about? Physical violence, absolutely. And so most programs if they are asking a question at all about violence, they are asking the question have you been hit, kicked, slapped or choked, right? They are not asking typically asking questions, again, in my experience talking to particularly in this Healthy Start Program, they are not asking questions about sexual violence and they are not asking other kinds of questions about power and control in that relationship that may be impacting their pregnancy.
And so this was really interesting for us because, again, stigma around these bad moms who have been told to not get pregnant, given access to birth control, and here they are pregnant again, what's wrong with her, and really maybe be able to think to ourselves, well maybe we missed the boat in our program.
So part of what we were looking at in our project is how do we define success when we are looking at these Healthy Start programs around screening for family violence. So I'm out there and that's the job is to encourage folks to do a better job of screening for violence.
A lot of folks equated screening for violence with the number of folks who are screened for violence with success in their program. And so I wanted to throw out one slide about general statistics and I know Hank gave us a bunch earlier, and then I wanted to bring it down to a smaller level. And it was a large hospital that I worked with in a state that has to remain unnamed because that's the way it works with her, so you're not allowed to name the places you went to visit.
This is a large urban area in the south. This is a very well thought of hospital. And in fact, it's a unique setting because they, unlike most programs, have on site violence folks 24/7 that responds to anybody's needs in the whole system. And this hospital is a traditional hospital, but they also have outpatient clinics. They have any other kind of mental health services, everything you would want as a one-stop shop for this community. And this program has 7,000 employees and they also have 16,000 live births a year. So this next little piece is really important. So again, access 24/7. There's universal screening in the setting, all patients are asked about violence. This slide comes from the year 2002. The number of folks who were served by their victim program during that year was 740 patients.
REBECCA WHITEMAN: As a way for the program internally to look at quality improvement, quality assurance measures and say, you know, maybe just having a question on the form isn't enough. Maybe we're missing something.
An example of another Healthy Start program and how we can use data sort of at this smaller level to make a difference in terms of changing our program. They started checking data on their clients last January. So they had seen 213 clients that they were collecting data on in their program at the time I saw them.
They had a 36 percent positive disclosure rate across the board in their program, and then I asked them to break it down site by sight. One of their sites had zero disclosures, and another site six miles away, same patient population, and this is Healthy Start, at the federal poverty level or below, had a 46 percent positive disclosure rate. So the population six miles apart in this little town in the middle of the country, things look really different down the road? Of course not. So what was happening in that site that was different than what was happening in this other site, and how do you capitalize on that, how do you figure that part out?
So what we ended up shifting ‑‑ this is something at the Family Violence Prevention Center that we shifted, because we had, for all this time, been encouraging programs to talk to patients about violence, so it's all about your screening rates, how many people were asked. And that certainly is a part of it.
But what became clear to us as we started going through programs is it's more than that, that in fact getting a sense of how many folks feel comfortable disclosing, how many people will come forward, how we're connecting with them is really important. And, in fact, how people go about asking these questions is really different from site to site.
So what happened here was there was a fabulous nurse and a fabulous social worker at this site, and they were able to go over and do some more training and support for this staff that weren't getting any disclosures of theirs.
These are just some take‑away questions for you all so you can go home and ask what your assessment rate is, how many patients are you asking about this, but also what is your personal positive disclosure rate, what is your program positive disclosure rate as compared to another program in your community to get a sense of where else might you be able to improve.
Something else that came up at all of these sites that I think is just really important and worth mentioning is that so many staff are affected by violence. And one of the things that we saw in our project is that the program typically dealt with case management as one size fits all. You're a case manager, you deal with all aspects of something that would come up with your client, and that was the requirement of your job.
We also learned that most of the programs where these folks were going out in the community to do this work didn't have an employee assistance program that dealt with the issue of violence. Nobody talked to them about the issue of violence when they came on board as new hires. So this wasn’t an issue that was particularly comfortable addressing internally.
And what we learned as we were connecting the dots here with the program and going back to my sight that shall be nameless that had the site with the zero disclosures, is as I was doing these trainings and sort of asking folks in the audience about their experience with screening, people would say the truth every once in a while.
And one of the women in a big hall, about this big, about this many people, said, you know, Rebecca, I do ask all my clients about violence ‑‑ and she does this. And it's great because she felt comfortable to do this ‑‑ and I pray to God each time they say no.
And that was just honest. It was really honest. And so the next woman that I went and observed was a woman at another site, and she knew I was coming there to see how she was doing her screening for violence. And so she spent a lot of time talking about all the other things related to perinatal stuff. She talked about PICA, she talked about diabetes, she talked about the HIV test that was coming up. And then she got to the violence question. And she knows I'm sitting there, and she says to the woman in front of her, "So you're not experiencing" ‑‑ very
compassionately ‑‑ "any violence in your relationship, are you?" Do you think that woman got any yeses when she asked that question?
But what was great about it is it was true, and that was the truth. And I think that's the truth in a lot of programs. And this whole idea that we're all in a position to ask these questions, to feel comfortable asking these questions, it's kind of crazy.
And so as we kind of went around and worked with folks we said, well, maybe we should think about doing this differently in your sites.
I'll tell a quick story about my own staff. As I said, I was a clinic director for a Plant Parenthood for a really long time, and I loved my staff. I knew what kind of birth control method they used, I knew what their kids did after school, I knew how often they and their partners had sex, blah, blah, blah, and I knew all about them, right? And I did my first training on domestic violence for my staff to get them ready to go out there and work with the clients. Four of my staff, who I knew so well and so intimately, disclosed domestic violence to me, and I had no idea. At this point this is a staff of, you know, 25 women, two of whom were in actively violent relationships at that time, two of whom had been in past relationships, one of whom had been such ‑‑ she had been battered so horribly while she was pregnant, and there was a crime involved. She was locked in the trunk. He did a lot of jail time for it. And other than the parents, nobody knew. None of us knew.
And so all of a sudden that big light bulb thing went on, and I learned that some of the best people to talk about violence were people who have been exposed to it and have their own stuff, and some of the worst people to do the screening were folks that had been through the same encounters.
I see some nodding.
Cindy was one of my staff, and she was a single mom, two kids, got in a really awful abusive relationship, and she was happy to ask you that question about are you being hurt, do you feel safe, here's the phone number, you know, you're not alone. She could say all that stuff because she had been there, and she was happy to connect with people like that. But if you came back into the clinic and you hadn't gone to shelter and you hadn't gotten out of that relationship, she was not happy. And so we didn't have Cindy do that anymore. You know, that's bad. We wouldn't want that.
And the flip side of that is the woman I described to you that had been locked in her trunk because ‑‑ the man that had done that at the time had been incarcerated for that for years, a couple years. He had battered her so badly, and the (inaudible). But she was the perfect person to sort of meet people where they were, support them as they were, working on their path no matter where they were, whether they were going to leave or not.
So anyway, this idea that we've done a good job with connecting to our staff around the implications of this for themselves I think is place we really have a lot of work to do. And I sort of added myself in the story because I certainly realized I had a lot of work I needed to do in preparing them to do screening.
I want to talk about another way data was used and a lot of creativity was used in a program, incredibly successful. This was a program with ‑‑ when I say no resources, think again ‑‑ no resources.
This is a rural southern town. The average family income for the girls that they were serving was $3200 a year, and the repeat teen pregnancy rate for teens in that state was 22 percent. In their Healthy Start program, they were able to bring that number down to 8 percent. And these are folks who are working with the hardest group you can imagine. And this is all about Mr. Eddie. And this is how I think creativity is just a wonderful thing.
Mr. Eddie was a white man. This was a program that served ‑‑ I think a hundred percent of their population were African‑American teen girls. A white man in the program. They had changed some time before the way they handled home visitation. So the first time they came in to the site, you got to meet the whole team, but you got to go there so that there was no stigma around judgment and someone going into your house and kind of checking you all out and seeing what your environment looked like.
So a teenager would come in, and she'd meet the nurse, she'd meet her case manager, she'd meet some other people in the program, and then she'd meet Mr. Eddie. And Mr. Eddie was known for his chili in that town, and he was also known as a good man because he had five daughters, and he knew more about hormones than any other man you've ever met.
And these teens felt ‑‑ so if you have a problem, Mr. Eddie, not only does he have the bucket‑size, you know, Kleenex dispenser in his office, he's also got a buck‑size thing of chocolate and he's got ‑‑ you know, he gets it.
Mr. Eddie was a social worker, and Mr. Eddie was never identified as a social worker. He was part of the team, he was there to help you, he was there to support you. And that was really important in this community, not because social workers aren't good people, but because I think there's so much stigma for a lot of folks around social workers because these are the folks who do what? Take your kids. Right.
So even if there are great social workers in your program who are there to do the best thing, how do we connect them and take the stigma away? And that was one example of a program. And I know he's an instrumental part of bringing that rate down to 8 percent and being able to talk to folks about violence, as well as all the other stuff in their program.
He did other really innovative stuff like connecting folks to after‑school programs and finishing their education and monitoring, and he even did something called ‑‑ I'll just keep talking about him for a minute because I'm not done with this slide for the moment ‑‑ they even did a program called etiquette night.
So I told you, again, these girls were from homes where the average income was 3200 a year, so they'd never been in a restaurant with linen on the table or (inaudible). So the idea of that program was to bring them to the table so that they could feel a part of it. And I, again, thought it was really innovative.
The other piece that we've brought to this program that is different, and this is also very new to Family Violence Prevention Fund ‑‑ although our name is Family Violence, I have to say that we are the U.S. Department of Health and Human Services national resource center on domestic violence and healthcare, not family violence and healthcare.
Well, we had to do some looking at our own stuff along the way as we were looking at the evidence and the data that's out there. And, actually, we know far more in some ways about what happens to kids exposed to violence, what happens to their health, than we do with adult women who are exposed to domestic violence. So we had to say, well, now, wait a minute. We know so much about what happens to folks at other times in their lives, how come we're not incorporating this into what we do?
I mentioned this before, because we're going to talk a little bit about those kinds of screening questions, but most folks in current programs, they focus on current physical abuse. And I've seen folks even say, "Are you in a relationship now" and "Are you in a relationship with someone that's hurting you now?" Well, if you broke up with that abusive boyfriend three weeks ago, that answer is no. And so, again, just sort of looking at the language around your questions I think is really important in terms of how you're going to capture what's really happening with your patients.
Most don't ask about childhood exposure to violence. Most programs don't make the connection between violence exposure and the impact on parenting. Hugely important. And I'll tell you another story.
I was ‑‑ Justine had mentioned that I often speak as a survivor of abuse. My mom was battered for 25 years, and I'm an incest survivor. And the co‑occurrences, as you know, 50 percent of homes, I think, with domestic violence, their kids do experience physical or sexual abuse.
And I was a very lucky, lucky woman. I got through college, I ended up with a nice partner, not an abusive partner, I had a planned pregnancy, a wanted pregnancy. I got to say yes to that question. I read all the books, I'd been to college, and I had this great, darling, perfect little baby boy. And you know how you go from washing your baby in the sink in the kitchen because they're so little, you can't bring them in the bathtub, and then you transition them to the bathtub?
And so I had this really cute ‑‑ I don't know, he must have been probably two months old at that point, he was big enough, maybe three, and I put him in the bath. And a lot of the sexual abuse that happened to me happened in the bathtub. I had this baby in the bathtub, and I had a panic attack, and I don't even know what it's called. My hands and feet go numb, everything gets really closed, and you feel like you can't breathe.
And all of a sudden I realized I'm responsible for this little creature and I'm having this weird out‑of‑body experience and I can't tell you why. Did I talk to my pediatrician about that? I didn't. Did I come up with some other way to handle that so I wouldn't experience that again and potentially drown this perfect little, you know, three‑month‑old baby? Yeah. My husband at that time did the bathing.
Would it have been helpful for me in a program to have somebody say to me, "You know what? If your heart's been talking to you, there may be triggers that you can't even imagine that are going to come up for you as a parent, and I just want you to know, here are some resources for you. There may be things that come up for you in anger or there may be other things that come up for you, and you can expect that, can expect that's going to happen, and it's okay, it happens to lots of folks."
The whole issue of normalization of what happens, how often it happens and then what the aftermath of that looks like is, I think, really important for folks.
So I think another important piece to this is that we look at screening for lifetime exposure to violence as an opportunity to primary prevention of child abuse. We know that moms who have been victimized by a partner are more likely to have depressive systems and report pressure parenting, but we're not talking about that in our programs, and I think we can be if we ask some questions about what happened to them as kids.
I mentioned this already, but families with DV are twice as likely to have substantiated cases of child abuse. How many of you in your programs are talking to moms about the co‑occurrence of child abuse in homes with domestic violence? Very good. I wish I could see a hand up for everybody in this program. And that's really a goal of our work is to see that connection, because I think a lot of times moms think that they can control what's happening and it gets limited to them. I just think that's another important piece.
Some other pieces that we talk a lot about ‑‑ and for those of you who have had the opportunity to listen to Bruce Perry or Linda Chamberlain talk about the impact of violence on kids' brains, we heard a little bit about the impact of seat belt injury and car crash injuries on babies and development and miscarriages and the like. Certainly we know that kids exposed to violence and infants exposed to violence have eating and sleeping problems, decreased responsiveness to adults ‑‑ you know, you go "goo, goo, goo" to that baby and it's just not giving you that back ‑‑ and increased crime. We absolutely know that because of our ability to do MRIs, we're able to really see that there's differences in the way brains look when a kid has been exposed to violence as opposed to a kid who grows up in a normal home.
So we also know that kids, as they get older, they're more likely to have failure to thrive issues. And again, in your programs that are looking at issues like that, failure to thrive with infants, I don't know if that's a connection to ask me about domestic violence, but my question to you is could it be.
Failure to thrive, headaches, bed‑wetting, speech disorders, vomiting and diarrhea. No surprise. Depression, anxiety, developmental delays are the other things that you see with kids. And then, of course, nightmares, sleep disturbances, aggressive behaviors and disturbances in peer relationships.
As they get older, they're more likely to go to the nurse, they're more likely to do badly in school, go to a speech pathologist and have lower grade point averages.
You're going to get a copy of my slides, and I'm just going to quickly tell you that some of the ‑‑ I put in some resources for you all in terms of programs that can be really helpful. There's one in Massachusetts ‑‑ there's one in Massachusetts , there's another one that we ‑‑ here's our information on the pediatric consensus guidelines, and then here's some other recommendations for the program.
So thank you for listening.