Rosy Miranda recognized herself in the desperate woman on TikTok. With tears in her eyes, the woman showed the bruises on her face, a black eye and a cut lip.
“No woman should have to go through this,” the woman had written in the captions of the video, set to a song in Spanish about domestic violence. “I know I’m going to get through this with my children. God, please give me strength.”
The video reminded Miranda of a time, more than a decade ago, when she too had felt trapped in an abusive relationship. At the time she was pregnant and, like the woman in the video, fearful for her future and that of her child.
She rapidly typed a message to the woman in the comments.
“If you need help please contact me,” she wrote. “I’m a community health worker. I can connect you with a domestic violence agency.”
In her work as a “promotora,” or community health worker, Miranda knows that violence against pregnant women and new mothers is all too common. At the San Jose nonprofit she volunteers for, Next Door Solutions to Domestic Violence, as many as 1 in 5 survivors seeking help have experienced intimate partner violence during pregnancy or the postpartum period. Pregnant people are more likely to die from homicide, which is often linked to domestic violence, than from any pregnancy-related health condition.
Violence in the home is increasingly being seen as a public health problem, and across California, organizations like Miranda’s, are working on anti-violence solutions to improve outcomes for parents and their babies. Efforts include working with physicians to better detect and help pregnant people who are experiencing abuse and advocating for legislation that would provide grants for innovative solutions.
“When you have providers even mentioning (domestic violence) it sends a message to patients that this is something that’s important, that this is a health issue, not just a criminal justice issue,” said Virginia Duplessis, associate director of health at the San Francisco-based Futures Without Violence. “The more we can have people in the health care field helping patients make the connection, the more we’ll be able to prevent and respond effectively.”
An estimated 324,000 pregnant people in the United States experience domestic violence annually. For about 1 in 6 the abuse starts for the first time during pregnancy. Pregnant people who experiences domestic violence are at increased risk of suffering pregnancy complications, miscarriages and bleeding, as well as mental health issues such as postpartum depression and substance use disorder. These conditions can gravely impact their health and the health of their babies. In the most extreme cases, domestic violence leads to death. A 2021 study of maternal deaths in the U.S. found that women were more than twice as likely to die from homicide during pregnancy and the year following childbirth than from hypertensive disorders, hemorrhage and infection.
Yet despite the outsized role of domestic violence as a driver of death, injury and disease during pregnancy and the postpartum period, this fact is often overlooked by health providers and policymakers, said Virginia Duplessis, associate director of health at the San Francisco-based Futures Without Violence, which works to end violence against women and children around the world.
“We know that for pregnant people who die during pregnancy, it’s often associated with domestic violence,” she said. “To me it’s always just been kind of mind boggling that as a field addressing maternal mortality, intimate partner violence (and) domestic violence has not been one of the main things that is being addressed.”
While domestic violence can affect people from all walks of life, people of color are disproportionately impacted. Almost half of Black and Native American women report physical or sexual violence or stalking by an intimate partner in their lifetime, around 20 to 25 percent higher than the rate among non-Hispanic white women. Experts point to a variety of factors influencing these high rates including the effects of socioeconomic challenges interpersonal and systemic racism, over-policing in communities of color and the fact that people with more resources may be better able to keep domestic violence as a private matter without getting authorities involved.
Black, Native American and Latinx people also experience greater rates of maternal mortality and pregnancy-related illness than whites. For example, Black women and indigenous women are about 3 times more likely to die during pregnancy than white women. Women in majority Hispanic communities are 32 percent more likely to suffer birth complications than those living in predominantly white areas. Data from the California Department of Public Health shows that Black, Hispanic, teenage and low-income pregnant people all experience higher rates of physical, psychological and sexual intimate partner violence.
The pandemic has likely worsened these risks as domestic violence rates soared due to more people being stuck at home in abusive relationships and overall stress on families. In fact, a recent report found that maternal deaths jumped 14 percent overall during the first year of the pandemic — and the rate was even higher for Black and Hispanic women. Experts attribute much of the rise to COVID-19, which poses a greater risk to pregnant women, and to disruptions in obstetric care.
The report did not look at cases of violent deaths. However, domestic violence can contribute to maternal stress which in turn may increase the risk of pregnancy complications, said Maeve Wallace, a reproductive and perinatal epidemiologist at Tulane University. A study she led found that women living in states with higher levels of violent crime are at greater risk for both pregnancy-related death and pregnancy-associated homicide.
When researchers compile the statistics, “sadly I do believe we will see an increase in maternal homicide during 2020 compared to previous years, given the increase in domestic violence and socioeconomic hardships that resulted from the COVID pandemic and the increase in homicide in general that occurred,” she wrote in an email.
Pregnancy and the birth of a child can spark or exacerbate violence in a relationship for a variety of reasons. Often it’s because the abusive partner feels they have less control over their partner, or they feel threatened by the attention being paid to the pregnant person or the new child, Duplessis said. Having a child can also put financial and emotional strain on new parents, increasing the risk of violence. Or the abusive partner may be angry over an unplanned pregnancy.
‘Before they get to that point’
While pregnant with her daughter, Miranda remembers doctors asking her if she was experiencing domestic violence on at least three occasions during prenatal visits. Each time she said no. She worried the doctors wouldn’t believe her if she told the truth or, even worse, that they might call the police and she’d get deported (she was undocumented at the time) or sent to prison and lose her child.
Asking pregnant patients about domestic violence is standard practice among health care providers, said Duplessis. But many patients are not comfortable disclosing abuse. Sometimes that’s because the questions are asked when the abuser or other family members are in the room. Or the question is posed in a way that discourages patients from saying yes such as “this isn’t happening to you, right?” Other patients, like Miranda, are afraid of legal repercussions, or don’t trust the provider enough to acknowledge the abuse. Even when survivors do disclose they’re in a violent relationship, health care providers don’t always have the right resources or knowledge to effectively help them, Duplessis said.
Futures Without Violence is leading an effort to train health care providers on how to better screen for and respond to domestic violence among patients, including by encouraging health care systems to partner with local agencies that help survivors. The organization is also pushing doctors to provide information to all of their patients about the impact of domestic violence on health and where to get help, rather than limiting these resources to patients who report it. That way, even if patients don’t disclose violence to the doctor, they’re armed with knowledge about what to do.
Next Door Solutions to Domestic Violence in Santa Clara County is one domestic violence agency supporting this effort by providing training and information about their services to local OBGYNs and other health care providers, said said Erica Villa, manager of community prevention.
“Everybody goes to the doctor at least once a year, if not for themselves then for their kids. But by the time they come through our doors something already happened, they’ve already experienced severe abuse, or they’re already in that situation where they’re fleeing,” she said. “We want to get (to) them before they get to that point.”
Listening to cries for help
Some health care providers and community educators who work with pregnant people and new parents are even better positioned than doctors to notice signs of domestic violence and to provide resources that can help. Doulas, for example, provide continuous physical, emotional and educational support to mothers during childbirth and pregnancy. Some doulas and doula collectives are now working to more intentionally incorporate screening and information on domestic violence into their practices.
Likewise, home visiting programs for pregnant people and new parents offer an opportunity to detect abuse and offer help to survivors. Ashley Skiffer-Thompson supervises a home visiting program in Los Angeles for pregnant people and parents of children 5 and under. Called Healthy Families America, the program supports families at high risk for domestic violence, substance use, child maltreatment, and homelessness because of family history and circumstances. Some clients referred to the program have already disclosed past or present experiences with domestic violence. Home visitors screen all clients repeatedly for intimate partner violence using a standard screening tool and receive training on how to look out for and respond to signs of an abusive relationship.
Red flags that home visitors look for include signs the mother is isolated from friends and family or has no access to the family’s finances. A home visitor might also notice that the partner is constantly hovering in the background but not participating in sessions, or seems controlling or disrespectful. Sometimes the danger is obvious, said Lisa Melville, associate director of another Healthy Families America program in the Antelope Valley. She recounted an incident in which a mother came out of the house on a cold day wearing a t-shirt, revealing adult-sized bite marks on her body.
“That was her cry for help,” Melville said.
Like doulas, home visitors work hard to build trust with their clients and spend significant time with them. Even so, it can be difficult to get survivors to open up about domestic violence, particularly in communities of color where distrust of the social services system often runs deep, due in part to structural racism and past trauma, said Ashley Skiffer-Thompson. Children of color are disproportionately represented in the child welfare system, for example, which researchers believe is at least in part due to racial biases of those working in the system. Home visitors are also mandated to report violence to authorities if it poses a threat to children, which may further discourage survivors from coming forward.
It can take months or even years for clients to confide in a home visitor, said Maria Moya, a supervisor with the Antelope Valley program. Even if clients in abusive relationships don’t open up, home visitors offer them information about intimate partner violence and where to find support. They may refer parents to therapy or parenting classes, and work with clients to create safety plans that identify people and resources they can turn to if they decide to seek help.
‘Why did I think I couldn’t?’
At the state level, the California Department of Public Health collects data on intimate partner violence, including during pregnancy, in order to better understand the circumstances surrounding violent deaths, spokesman Ronald Owens said in an email. The department also funds several home visiting programs and pilot efforts aimed at addressing and preventing intimate partner violence generally, including among pregnant teens.
Last August, at the federal level, five Democratic senators introduced a bill called the Protect Moms from Domestic Violence Act. The bill would direct the Department of Health and Human Services and the National Academy of Medicine to study the extent to which people are more at risk of maternal mortality or severe maternal morbidity as a result of being a victim of intimate partner violence, dating violence, sexual assault, stalking, human trafficking, sex trafficking, child sexual abuse or forced marriage. It would also provide grants for innovative approaches to address the problem. However, the bill has not yet made it through the committee stage and is not expected to pass.
For Miranda, educating others about intimate partner violence and options for seeking support is now her passion. She’s part of a group of Spanish-speaking promotoras working to provide information on the subject to fellow community members, and to dispel common fears about seeking help. Although her daughter was born healthy and is now a vibrant 13-year-old, it took Miranda 10 years to leave her relationship and she believes the abuse impacted her long-term mental and physical health.
Now Miranda strives to help others in domestic violence situations find safety much sooner. She never heard back from the woman on TikTok, but if she had she would have told her all the things she wished she’d known as a new immigrant to the United States: That there are domestic violence agencies that can help with shelter, food, clothes, legal expenses and money for rent. That you won’t get in trouble or lose your children for reporting domestic violence.
Leaving is possible, Miranda tells survivors, and there’s light on the other side.
“One day you’ll laugh…,” Miranda said. “You’ll think, why did I think I couldn’t? I’m so strong.”
If you or someone you know is experiencing domestic violence, contact the National Domestic Violence Hotline at 1-800-799-7233 for support and referrals, or text “START” to 88788.