Two in five women in the United States, and 35 percent of women in California, experience intimate partner violence (IPV), including physical, sexual, or psychological abuse. IPV occurs and can escalate during pregnancy and postpartum, contributing to adverse maternal and infant health outcomes, including death. Pregnant people experiencing IPV are less likely to get adequate prenatal care; more likely to have stillbirths, pelvic fractures, and preterm delivery; and twice as likely to have postpartum depression. Alarmingly, pregnant people are more likely to be murdered during or right after pregnancy than they are to die from the three leading obstetric causes of maternal death: hypertensive disorders, hemorrhage, or sepsis.
Mathematica partnered with Blue Shield of California Foundation and Futures Without Violence to develop evidence-informed policy recommendations to prevent IPV among pregnant and postpartum Medi-Cal and other state Medicaid beneficiaries, and to improve maternal and infant health. The California Department of Health Care Services (DHCS) is an early leader in putting these recommendations into action.
“Medi-Cal is a huge system that affects millions of Californians with low incomes, and it has the power to improve maternal and infant health by preventing IPV among pregnant and postpartum women,” said Debbie I. Chang, president and CEO of Blue Shield of California Foundation. “We commend state health leaders for taking steps to improve the system and encourage them to do even more. IPV is a preventable, multigenerational problem, and IPV education and screening are proven ways to break the cycle.”
Emerging state initiatives offer a powerful opportunity to transform maternal healthcare encounters into a vital force for safety, healing, and empowerment.
DHCS’s new Birthing Care Pathway (BCP) initiative offers an unprecedented chance to meaningfully address IPV and reduce maternal morbidity and mortality among Medi-Cal members, who account for 39 percent of births in California. Building on augmented Medi-Cal maternal health benefits implemented in 2022 and 2023—such as expanding coverage to 12 months postpartum and covering doula care—the BCP addresses the physical, behavioral, and health-related social needs of pregnant and postpartum Medi-Cal members. “At the heart of the BCP is the concept that the patient does not achieve a healthy pregnancy journey just inside the healthcare system, but at the intersection of community, public health, and healthcare,” said Dr. Amanda P. Williams, physician leader and clinical innovator in obstetrics-gynecology and member of the BCP’s clinical care workgroup. “IPV is a critical issue for pregnant and postpartum patients that crosses all three of these domains.”
Through the BCP initiative, DHCS plans to implement two of our recommended IPV policies, designed to improve the health and save the lives of pregnant people and their babies, and is exploring two other policies that could have even greater impact. A preview of the initiative indicates that DHCS plans to:
- Ensure that Medi-Cal risk assessments include IPV screening. Although states with Medicaid expansion programs, such as California, must cover IPV screening and referral services, IPV screening practices for pregnant and postpartum people are inconsistent and make limited provision for resources, follow-up, or supports. Spotting and addressing safety risks early in a person’s pregnancy opens the door to intervene and prevent injury and other health-related harms. “It is reassuring to see DHCS addressing an issue as devastating to maternal health as IPV. IPV screenings for women of reproductive age, along with partnerships between managed care plans and community providers, are crucial for preventive and trauma-informed care,” said Dr. Karen Ramstrom, chief of the Maternal and Infant Health Branch of the Maternal, Child, and Adolescent Health Division at the California Department of Public Health.
- Reframe all maternal health services with a trauma-informed lens. Recognizing the impact of IPV, adverse childhood experiences, community violence, and systemic racism is vital. “By using a trauma-informed approach along the care continuum, screening all patients, and referring them to medical and community resources, as needed, we can help families have the safe, affirming birth experience they deserve,” said Dr. Williams.
Standardizing universal IPV education and training healthcare providers can maximize opportunities to improve maternal and infant health.
We commend the BCP for taking meaningful steps to address IPV. For a more impactful approach, we encourage DHCS to build on these initial steps by implementing two additional policies it is currently exploring. Specifically, (1) require managed care plans to promote universal IPV education in healthcare settings and (2) incorporate IPV training into required network provider training.
- Promote universal education. Research shows that screening alone is insufficient and often results in non-trauma-informed practices that might not identify cases of IPV or connect survivors to needed supports. Fear of judgment, shame, worries about data privacy, and concerns about child welfare involvement make disclosure challenging, and the disclosure itself can amplify a survivor’s immediate risk of harm. Thus, rates of disclosure in healthcare settings are much lower than the known prevalence of IPV.
Universal education—a safer approach in which healthcare staff speak to all patients about healthy and unhealthy relationships, the health effects of violence, health promotion strategies, and safety resources, regardless of disclosure—is essential, whether combined with or in place of screening. To promote this approach, Futures Without Violence developed the evidence-based, trauma-informed Confidentiality, Universal Education + Empowerment, and Support (CUES) intervention, which provides information cards to support provider−patient dialogue and gives patients resources such as safety hotlines and counseling options. Relatedly Dr. Ramstrom broadly endorsed preventive strategies, “The California Department of Public Health recognizes IPV as a significant public health issue and has addressed domestic violence through a primary prevention approach aimed at promoting healthy behaviors and environments to stop violence before it occurs. - Train healthcare providers. Proper training is key to helping ensure providers are sensitive, nonjudgmental, and equipped to offer effective support. Poorly conducted screenings can reinforce stigma, retraumatize survivors, and discourage future disclosures or help-seeking. Many healthcare providers lack this important training. Primary care clinicians (including obstetricians) said common barriers to IPV screening include limited time, concerns about patient privacy and safety, and lack of training. The lack of consistent and effective IPV screenings leads to missed opportunities to offer support, which can have severe consequences. Comprehensive training, informed by IPV organizations and survivors, helps providers feel more confident in addressing IPV with their patients.
DHCS and other state Medicaid agencies should work with managed care plans and IPV advocacy organizations to promote universal education in clinical settings and to develop and require standardized IPV training for healthcare providers and staff. Policymakers and managed care plans should monitor the impact of these policies on maternal health outcomes to build the evidence for further adoption and scaling of these policies.
It is crucial for all parties interested in maternal health across the nation to recognize the importance of these recommendations and to explore paths for implementing similar IPV strategies. By doing so, we can create a safer, more supportive environment for pregnant and postpartum people and improve maternal and infant health.