When Margot Newman* went into labor, her boyfriend broke her cell phone and hogtied her to the toilet in their cramped bathroom. If she left, or screamed, he said he’d kill her.

As her contractions grew stronger, she pleaded for him to let her go to the hospital. Finally, he allowed her to go to her sister’s house nearby, and she took Newman to the Ojai Valley Community Hospital.

“I prayed and prayed and prayed that I could get through the day,” Newman said. “We finally got to the hospital and my blood pressure was really high, and I had really high contractions, because he had put me in to labor.”

Her son, Landon, was born after 30 hours of labor and a number of medical interventions, due to Newman’s high blood pressure and other complications, likely stemming from the abuse she’d experienced in the days before, her doctor said.

Her doctor didn’t know about the severity of abuse beforehand, but had provisions of the Affordable Care Act been in place, he might have. Under the new federal law, health care providers are required to offer domestic-violence screening and counseling to all women, and health insurance companies are required pay for those services.

“An estimated 25 percent of women in the United States report being targets of intimate partner violence during their lifetimes,” reads a fact sheet on the coverage from the federal Department of Health and Human Services. “Screening is effective in the early detection and effectiveness of interventions to increase the safety of abused women.”

Health care providers statewide have been working to implement the new requirements since they took effect in August 2012. Meanwhile, activists and those who work with domestic violence victims say the provisions are a good start, but still not enough to solve the problem.

“I just think this is a really big problem and I think we have to improve the OBGYN comfort level with intervening and improve the skills set to intervene,” said Priya Batra, a women’s health psychologist who helps lead a domestic violence taskforce in Sacramento. “The most helpful intervention is saying, ‘This is not OK, you do not have live this way, there is hope out there for you.”

If they didn’t do so already, most health care providers have added a domestic-violence screening aspect to their “well-woman exams,” or annual checkups. But, depending on the provider, the screening could range from simply asking women experiencing abuse to check a box on an intake form to the physician taking several minutes to ask each patient a series of questions.

“I encourage clinicians to ask, ‘How are things at home?’ something that’s a conversation,” said Brigid McCaw, an internal medicine doctor and the medical lead of Kaiser Permanente’s Family Violence Prevention Program in Northern California.

“I will often follow it up with, ‘Do you ever feel physically or emotional threatened or hurt by your partner or spouse?’” To help them comply with the new law, some doctors, nurses and therapists are also receiving special training on how to help women experiencing domestic violence, something McCaw believes should be standard, she said.

“This is so common, unfortunately — one out of four women will experience intimate-partner violence in their lifetime — and you can’t tell just by looking on an age or social or economic status or education or religion or sexual preference,” she said. “So screening every woman when they come in for a well-woman visit or other conditions or concerns is absolutely warranted. There’s no way to know unless you ask.”

There’s also a lack of emergency shelters and transitional housing for victims, whose ability to escape the abuse often hinges on having another place to live, Batra said.

According to the 2012 National Census of Domestic Violence Services, a survey taken by all domestic violence agencies statewide on Sept. 12, the agencies served 5,258 victims in California that day. On that same day, the groups were unable to meet 1,170 requests from victims for help. About 68 percent of those requests were for housing — both emergency and transitional.

Domestic violence often escalates during stressful life events, such as pregnancies, particularly if they’re unplanned or occur in tangent with economic difficulties, according to the California Partnership to End Domestic Violence.

Women who have been pregnant within the last five years experience 12 percent higher rates of intimate partner violence, according to the 2005 California Women’s Health Survey cited by the nonprofit.

Of those experiencing physical intimate partner violence, 75 percent of the victims in the survey had children under the age of 18 at home.

Domestic violence and abuse — whether emotional or physical — can take a toll on both a pregnant woman and her developing fetus, McCaw said.

“We’re just beginning to understand in the last 10 to 15 years how important the maternal experience is for how babies do,” she said. “The fear and stress related to intimate partner violence, even if there aren’t direct injuries, certainly has an impact on the developing baby and those risk can stay with the baby over time.”

Pregnant women living with abuse face higher chances of pre-term delivery, as well as pregnancy complications, such as high blood pressure. They also have higher incidences of depression, post-traumatic stress disorder and anxiety disorders, McCaw said.

A pregnancy can make it more difficult for a woman to leave an abusive relationship, particularly if she’s reliant on her partner for health insurance, money or housing, said Krista Kotz, program director for Kaiser’s Northern California Family Violence Prevention Program.

“In general, things that would make a woman more financially vulnerable make it more difficult for her to leave,” she said.

Ventura mother Dena Lopez* experienced severe abuse when pregnant with all three of her children, giving birth twice with black eyes, bruises and broken ribs, she said. Finally, after giving birth to a stillborn baby who she “felt sure was brain damaged because of the beatings,” she left her husband.

That was more than 30 years ago, and she’s now a grandmother and teacher at an adult education program in Ventura County. Lopez also volunteered at a local shelter for domestic violence victims.

“I talk to the women who are in the same state of mind that I was in, and I try to tell them, ‘You don’t try to stay together for the kids. In the end, the decision to leave, it’s a life or death choice,’” she said. “The biggest thing is just knowing you’ve got some outside support and that’s the one big reason that you stay or return.”

Newman, who was also beaten multiple times while pregnant, left her son’s father a few days after he was born, with $3 in her bank account. She wasn’t sure how they’d survive, but she found work as a waitress, got an apartment in Ojai and obtained full custody of her son.

Landon is now two and doesn’t remember his father.

“I didn’t want Landon to grow up thinking that it’s OK to treat women that way,” Newman said. “He’s such a sweet and loving boy. What happened before almost seems like a dream.”

* Names have been changed to protect the safety of victims of abuse.