With the end of October, National Domestic Violence Awareness and Prevention Month draws to a close. But year round, Maryland advocates are working to improve how health care providers identify and support victims of domestic and intimate partner violence.“People who are in abusive relationships have higher overall health issues, so they’re coming into the health care setting more frequently,” said Audrey Bergin, operations manager for the Maryland Health Care Coalition Against Domestic Violence. “By screening, you may reach someone before they’re at the point of seeking help and you’re able to at least plant the seed at that point of ‘You don’t deserve this. There is help available. Here’s where you would go to get help.’”Health care providers – and other community members who might interact with victims of domestic violence in health care settings – receive training on how to more proactively and effectively respond to victims of domestic violence.While many people think of domestic violence as purely physical, the training covers the many other ways in which someone might abuse their partner, such as controlling a partner’s finances, where they are allowed to go, or with whom they are allowed to spend time, said Lauren Dougherty, training and outreach specialist for the Maryland Health Care Coalition Against Domestic Violence.They also train health care providers on how to identify whether someone may be in an abusive situation; how to set a good environment for disclosure; how to respond in a caring and proactive manner; how to document abuse in a patient’s medical record; and when should something be reported.Maryland does not have mandated reporting of intimate partner violence, except in certain cases such as elder abuse or child abuse.Bergin said advocates prefer it that way because “we’re putting the control back in the hands of the victim or survivor.”“I ran a hospital-based program for 20 years…. [There were a] number of times that I was in the ER with a victim and the abusive partner was arrested, and then that was his first arrest and so he’s released on his own recognizance, and then that person is back home, has emptied out the bank account, or has gone and picked up the kid from daycare…. Now they’re additionally really angry because they’ve been arrested,” she said.She added that people from marginalized groups may not be comfortable with police intervention.Instead, Bergin said, it is important to allow the victim to be able to make their own decisions.“In the health care setting, we would tell victims that they could use their medical report to press charges down the road, and so maybe they want to get some money, pick their kids up from child care, get to a safe location, and then call the police.”In addition to training health care workers, the coalition also works with focus groups of survivors of intimate partner violence to help develop materials with resources for victims and survivors. Doherty said those focus groups have shaped the information in the materials, such as asking for the addition of a hotline or other mental health resources, or adding more language about financial abuse and the feeling of “walking on eggshells in my own home” to a list of abusive behaviors.Not only are the focus group members paid at the same rate as other experts in the field, but they also get the opportunity to share their experiences with fellow survivors and effect positive change.“The groups have a chance to sit with people who had been through similar experiences and that felt like they were really connecting with people,” Bergin said “It felt empowering for them to be able to do something that might have a positive impact on other survivors.”By training more health care providers and making resources more accessible to victims, Bergin hopes their work will address some of the disparities among those who are affected by domestic violence.“Anyone who’s experiencing any form of discrimination outside of their relationship – whether it’s racism, ageism, sexism – all of these can be mechanisms that are then, again, used by the abusive partner to further manipulate and control the victim in the situation,” she said, adding that they are also working to address bias and discrimination within the health care system itself.Those disparities can be even greater for pregnant individuals.Homicide was the leading cause of death among pregnant women, only recently surpassed by opioid overdoses. Abuse can also cause or worsen health issues associated with pregnancy, such as anemia, high blood pressure, premature birth, and low birth weight, Bergin said.“You’ve got people then at higher risk in terms of their procedure,” she said. “When you add on top of that bias because of the person’s ethnicity or socioeconomic background or race, as well as the potential bias about being in an abusive relationship … it kind of compounds things and can lead to greater disparities and health outcomes.”There is still much work to do, including making victims more aware of the costs they will incur for forensic medical exams – and eventually making it so victims don’t have to pay those costs at all, Doherty said.“Intimate partner violence victims end up having to pay for certain things that, were they a victim of crime from a stranger, would not have had to do,” she said. “Part of our hope is that that changes. But currently, our work is making sure that survivors know that there can be a cost associated with it.”Bergin also wants more training in medical and nursing schools about intimate partner violence, an area in which she said the curricula are currently lacking.“If somebody is being treated for chronic headaches and they’re in an abusive relationship but that’s not being shared, and the medical provider is not asking questions about it, is the treatment that they’re recommending going to be helpful?” she said. “Are they going through additional tests that are really maybe not necessary, as opposed to really getting down to the root of the problem and trying to help with some of that?”