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United States General Accounting Office: 
GAO: 

Report to the Honorable Eleanor Holmes Norton, House of 
Representatives: 

May 2002: 

Violence Against Women: 

Data on Pregnant Victims and Effectiveness of Prevention Strategies 
Are Limited: 

GAO-02-530: 

Contents: 

Letter: 

Results in Brief: 

Background: 

Available Data on Pregnant Victims of Violence Are Incomplete and Lack 
Comparability: 

Multiple Strategies Designed to Prevent Violence, But Effect Is 
Unknown: 

Concluding Observations: 

Appendix I: Scope and Methodology: 

Appendix II: Description of the Pregnancy Risk Assessment Monitoring 
System: 

Appendix III: Pregnancy Status Questions on States' Death Certificates: 

Appendix IV: Comments from the Department of Health and Human Services: 

Appendix V: GAO Contacts and Staff Acknowledgments: 

Table: 

Table 1: PRAMS Estimates of the Prevalence of Physical Abuse by 
Husband or Partner during Pregnancy, 1998: 

Figure: 

Figure 1: Pregnancy Status Categories on Proposed U.S. Standard Death 
Certificate Revision: 

Abbreviations: 

ACOG: American College of Obstetricians and Gynecologists: 

BJS: Bureau of Justice Statistics: 

CDC: Centers for Disease Control and Prevention: 

FBI: Federal Bureau of Investigation: 

HHS: Department of Health and Human Services: 

HRSA: Health Resources and Services Administration: 

NIH: National Institutes of Health: 

NIJ: National Institute of Justice: 

NVDRS: National Violent Death Reporting System: 

OJP: Office of Justice Programs: 

PRAMS: Pregnancy Risk Assessment Monitoring System: 

SAMHSA: Substance Abuse and Mental Health Services Administration: 

UCR: Uniform Crime Reporting Program: 

VAWA: Violence Against Women Act: 

VAWO: Violence Against Women Office: 

[End of section] 

United States General Accounting Office: 
Washington, DC 20548: 

May 15, 2002: 

The Honorable Eleanor Holmes Norton: 
House of Representatives: 

Dear Ms. Norton: 

Violence against women, including violence that results in homicide, 
is a significant health and criminal justice problem. The problem is 
magnified when the victim of violence is pregnant because there are 
additional health risks to both the woman and her unborn child. 
Objectives to decrease violence against women were included in Healthy 
People 2010, the nation's health promotion and disease prevention 
strategy.[Footnote 1] In response to its concerns about violence 
against women, the Congress passed the Violence Against Women Act 
(VAWA),[Footnote 2] which funds, among other things, programs to 
shelter battered women, training for law enforcement officers and 
prosecutors, and research on violence against women. 

Violence against women largely involves intimate partners, such as 
husbands, boyfriends, and dates. A recent federal report estimated 
that about 2.1 million women are raped or physically assaulted 
annually.[Footnote 3] Of surveyed women who reported being raped or 
physically assaulted since the age of 18, about three quarters 
reported being victimized by a current or former spouse, cohabiting 
partner, or date. 

Due to your concern about pregnant women being victims of homicide and 
other violence, you asked us to provide information on this problem. 
In response to your request, this report will discuss (1) the 
availability of information on the prevalence and risk of violence 
against pregnant women and on the number of pregnant women who are 
victims of homicide and (2) strategies and programs to prevent 
violence against pregnant women. 

To answer these questions, we interviewed and obtained documents from 
officials at the Department of Health and Human Services' (HHS) 
Centers for Disease Control and Prevention (CDC), National Institutes 
of Health (NIH), and Health Resources and Services Administration 
(HRSA) and the Department of Justice's Office of Justice Programs 
(OJP) and Federal Bureau of Investigation (FBI). We also interviewed 
and collected information from researchers and representatives of four 
states' departments of health and vital statistics, medical examiners' 
offices, local law enforcement, domestic violence coalitions, violence 
prevention programs, health care professional organizations, and 
advocacy groups. We reviewed literature on the prevalence and risk of 
violence toward women during pregnancy; we identified 11 studies 
published since 1998 that contained prevalence estimates. We conducted 
our work from July 2001 through April 2002 in accordance with 
generally accepted government auditing standards. (For additional 
information on our methodology, see appendix I.) 

Results in Brief: 

Available data on the number of pregnant women who are victims of 
violence, including violence that results in homicide, are incomplete 
and lack comparability. Our review found that there is no current 
national estimate of the prevalence of violence against pregnant women—
that is, the proportion of pregnant women who experience violence. 
Estimates that are available cannot be generalized or projected to all 
pregnant women. For example, CDC's Pregnancy Risk Assessment 
Monitoring System (PRAMS) produces estimates of the prevalence of 
violence, but only for women whose pregnancies resulted in live births 
and only for participating states. For 1998, PRAMS prevalence 
estimates for the 15 participating states ranged from 2.4 percent to 
6.6 percent. Many studies focus on narrowly defined populations and 
use varying definitions of violence, producing prevalence estimates 
that are not comparable. Research findings on whether women are at 
increased risk for violence during pregnancy are inconclusive. CDC 
reported that, while additional research is needed in this area, 
current study findings suggest that for most abused women, the risk of 
physical violence does not seem to increase during pregnancy. 
Moreover, some women who previously experienced violence do not 
experience violence during their pregnancies. Factors that studies 
have found to be associated with violence during pregnancy include 
violence before pregnancy, younger age of the victim, and unintended 
pregnancy. 

Little information is available on the number of pregnant homicide 
victims. Federal homicide data collected by CDC and the FBI do not 
capture the pregnancy status of female victims. Seventeen states try 
to collect pregnancy data on death certificates, but these data may 
understate the number of pregnant homicide victims because autopsies, 
if conducted, might not include examinations for pregnancy, and 
pregnancies, if identified, might not be reported on death 
certificates. Officials in the four states we contacted have attempted 
to improve the data by linking multiple data sources, such as medical 
examiners' reports and death certificates. However, some of these 
officials told us that they do not have the resources to conduct such 
database links on a continuing basis. CDC has begun two initiatives 
that could result in better data on homicides of pregnant women—a 
revision to the U.S. standard death certificate to include pregnancy 
status and a proposed national violent death reporting system, both of 
which involve federal and state participation. Continued federal-state 
collaboration to gather and analyze more complete and comparable data, 
such as these initiatives and PRAMS, could improve policymakers' 
knowledge of violence against women and guide future research and 
resource allocation. 

Health and criminal justice officials have designed multiple 
strategies to prevent violence against women, but their effect is 
unknown. Strategies to prevent violence against pregnant women are 
similar to those to prevent violence against all women. These 
strategies include public health efforts to keep violence from 
occurring in the first place and intervention activities that identify 
and respond to violence after it occurs, as well as criminal justice 
strategies that focus on incarcerating or rehabilitating batterers. 
Screening, or asking women about their experience with violence, is 
generally the initial component of interventions. However, recent 
studies found that fewer than half of physicians routinely screen for 
violence during prenatal visits. Reasons cited for physicians' 
reluctance to screen include lack of training on how to conduct 
screenings and not knowing how to respond if a woman discloses 
violence. Little information is available on the effectiveness of 
strategies to prevent violence against women, including batterer 
prevention programs and routine screening. CDC has not recommended 
routine screening for intimate partner violence because of the lack of 
scientific evidence about its effectiveness. HRSA is currently funding 
four small prevention projects, each of which includes an evaluation 
component. Evaluating the outcomes of violence prevention programs and 
strategies could help identify successful approaches for reducing 
violence against women. 

We requested comments on a draft of this report from the Attorney 
General and the Secretary of HHS. Justice informed us that it did not 
have any comments. HHS agreed that limited information is available on 
violence against pregnant women. In addition, HHS discussed several 
issues and efforts that it considers important regarding violence 
against women. 

Background: 

Violence against women can include a range of behaviors such as 
hitting, pushing, kicking, sexually assaulting, using a weapon, and 
threatening violence. Violence sometimes includes verbal or 
psychological abuse, stalking, or enforced social isolation. Victims 
are often subjected to repeated physical or psychological abuse.
The federal public health agencies that address violence against women 
include CDC, NM, HRSA, and the Substance Abuse and Mental Health 
Services Administration (SAMHSA). They focus on activities such as 
defining and measuring the magnitude of violence, identifying causes 
of violence, and evaluating and disseminating promising prevention, 
intervention, and treatment strategies. CDC's National Center for 
Injury Prevention and Control and National Center for Chronic Disease 
Prevention and Health Promotion have funded efforts to document the 
prevalence of violence against women, improve maternal health, and 
prevent intimate partner violence. CDC's National Center for Health 
Statistics operates the National Vital Statistics System, which 
maintains a national database of death certificate information. The 
National Center for Health Statistics has a contract with each state 
to support routine production of annual vital statistics data, 
generally covering from one-fourth to one-third of state vital 
statistics operating costs. NIH has funded research to study violence 
against women through several of its institutes—the National Institute 
on Alcohol Abuse and Alcoholism, National Institute of Child Health 
and Human Development, National Institute on Drug Abuse, National 
Institute of Nursing Research, and National Institute of Mental Health—
and the National Center for Research Resources. HRSA's Maternal and 
Child Health Bureau, as part of its mission to promote and improve the 
health of mothers and children, funds demonstration grant programs 
that focus on violence against women during the prenatal period. 
SAMHSA funds efforts focused on the mental health and substance abuse 
treatment of women who have been victims of violence. 

The federal criminal justice agencies that address violence against 
women are OJP's Violence Against Women Office (VAWO), National 
Institute of Justice (NIJ), and Bureau of Justice Statistics (BJS). 
Using VAWA funds, VAWO administers grants to help states, tribes, and 
local communities improve the way criminal justice systems respond to 
intimate partner violence, sexual assault, and stalking. VAWO also 
works with victims' advocates and law enforcement agencies to develop 
grant programs that support a range of services for victims, including 
advocacy, emergency shelters, law enforcement protection, and legal 
aid. VAWO administers these funds through both formula and 
discretionary grant programs.[Footnote 4] NIJ conducts and funds 
research on a variety of topics, including violence, drug abuse, 
criminal behavior, and victimization. BJS collects, analyzes, 
publishes, and disseminates information on crime, criminal offenders, 
victims of crime, and the operation of justice systems at all levels 
of government. 

The FBI administers the Uniform Crime Reporting Program (UCR). Under 
this program, city, county, and state law enforcement agencies 
voluntarily provide information on eight crimes occurring in their 
jurisdictions: criminal homicide, forcible rape, robbery, aggravated 
assault, burglary, larceny--theft, motor vehicle theft, and arson. The 
FBI assembles and publishes the data and distributes them to 
contributing local agencies, state UCR programs, and others interested 
in the nation's crime problems. 

CDC homicide data indicate that from 1995 through 1999, homicide was 
the second leading cause of death for women aged 15 to 24, after 
accidents. CDC data also show that almost 2,600 women of childbearing 
age (15 through 44) were homicide victims in 1999. BJS reported that 
intimate partner homicides accounted for about 11 percent of all 
murders nationwide in that year.[Footnote 5] Seventy-four percent of 
these murders (1,218 of 1,642) were of women. About 32 percent of all 
female homicide victims were murdered by an intimate partner, in 
comparison to about 4 percent of all male homicide victims. 

Available Data on Pregnant Victims of Violence Are Incomplete and Lack 
Comparability: 

There is no current national estimate of the prevalence of violence 
against pregnant women. Estimates that are currently available cannot 
be generalized or projected to all pregnant women. CDC's PRAMS 
develops statewide estimates of the prevalence of violence for women 
whose pregnancies resulted in live births; 1998 estimates for 15 
participating states ranged from 2.4 percent to 6.6 percent. Research 
on whether women are at increased risk for violence during pregnancy 
is inconclusive. However, CDC reported that study findings suggest 
that, for most abused women, physical violence does not seem to be 
initiated or to increase during pregnancy. National data are also not 
available on the number of pregnant homicide victims, and such data at 
the state level are limited. The two federal agencies collecting 
homicide data, the FBI and CDC, do not identify the pregnancy status 
of homicide victims. CDC is exploring initiatives that could result in 
better data on homicides of pregnant women. 

Knowledge of Prevalence of Violence during Pregnancy Is Limited, 
Although Several Risk Factors Have Been Identified: 

There is no current national estimate measuring the prevalence of 
violence during pregnancy-—that is, the proportion of pregnant women 
who experience violence. Some state- and community-specific estimates 
are available, but they cannot be generalized or projected to all 
pregnant women. 

CDC developed PRAMS, an ongoing population-based surveillance system 
that generates state-specific data on a number of maternal behaviors, 
such as use of alcohol and tobacco, and experiences—-including 
physical abuse-—before, during, and immediately following a woman's 
pregnancy. CDC awards grants to states to help them collect these 
data. The number of states that participate in PRAMS has increased 
since its inception. Five states and the District of Columbia 
participated in fiscal year 1987 and 32 states and New York City 
participated in fiscal year 2001. CDC officials reported that lack of 
funds has prevented additional states from being added; six states 
were approved for participation in PRAMS but were not funded in 2002. 
CDC's goal is to fund all states that want the surveillance system. 

The estimated 1998 PRAMS prevalence rates of physical abuse by husband 
or partner during pregnancy, which CDC reported for 15 states, ranged 
from 2.4 percent to 6.6 percent.[Footnote 6] (See appendix II for 
PRAMS prevalence estimates for the 15 participating states and a 
description of PRAMS's methodology.) States participating in PRAMS use 
a consistent data collection methodology that allows for comparisons 
among states, but it does not allow for development of national 
estimates because states participating in PRAMS were not selected to 
be representative of the nation. In addition, PRAMS data cannot be 
generalized to all pregnant women because they represent only those 
women whose pregnancies resulted in live births; the data do not 
include women whose pregnancies ended with fetal deaths or abortions 
or women who were victims of homicide.[Footnote 7] PRAMS is based on 
self-reported data and, because some women are unwilling to disclose 
violence, the findings may underestimate abuse. 

Studies have also estimated the prevalence of violence within certain 
states and communities and among narrowly defined study populations. 
These estimates lack comparability and cannot be generalized or 
projected to all pregnant women. Many of the studies do not employ 
random samples and are disproportionately weighted toward specific 
demographic or socioeconomic populations. Most of the 11 such studies 
we reviewed, which were published from 1998 through 2001, found 
prevalence rates of violence during pregnancy ranging from 5.2 percent 
to 14.0 percent. In a CDC-sponsored 1996 review of the literature, the 
majority of studies reported prevalence levels of 3.9 percent to 8.3 
percent.[Footnote 8] The variability in estimates could reflect 
differences in study populations and methodologies, such as 
differences in how violence is defined, the time period used to 
measure violence, and the method used to collect the data. 

Research on whether being pregnant places women at increased risk for 
violence is inconclusive. CDC reported that additional research is 
needed in this area, but that current study findings suggest that for 
most abused women, physical violence does not seem to be initiated or 
to increase during pregnancy.[Footnote 9] Although some women 
experience violence for the first time during pregnancy, the majority 
of abused pregnant women experienced violence before pregnancy. In one 
study we reviewed, only 2 percent of women who reported not being 
abused before pregnancy reported abuse during pregnancy.[Footnote 10] 
The same study also found that, for some women, the period of 
pregnancy may be less risky, with violence abating during pregnancy; 
41 percent of the women who reported abuse in the year before 
pregnancy did not experience abuse during pregnancy. Studies have 
found other factors to be associated with violence during pregnancy, 
including younger age of the woman, lower socioeconomic status, abuse 
of alcohol and other drugs by victims and perpetrators of violence, 
and unintended pregnancy.[Footnote 11] 

To increase the generalizability of research on the prevalence and 
risk of violence to women during pregnancy, researchers have reported 
the need for more population-based studies that would allow for 
comparisons of pregnant and nonpregnant women. These studies would 
draw their samples from all pregnant women, not just those receiving 
health care or giving birth, as well as nonpregnant women. Such 
research could indicate whether pregnant women are at increased risk 
for violence compared to their nonpregnant counterparts. Researchers 
have also suggested using methodologies that consistently define and 
measure the prevalence of violence. A recent report by the Institute 
of Medicine on family violence recommended that the Secretary of HHS 
establish new, multidisciplinary education and research centers to, 
among other things, conduct research on the magnitude of family 
violence and the lack of comparability in current research.[Footnote 
12] 

Pregnancy Status Often Not Reflected in Data on Homicide Victims: 

There is also little information available on violence against 
pregnant women that results in homicide. The FBI and CDC are the two 
federal agencies that collect and report information on homicides 
nationwide; however, neither agency collects data on whether female 
homicide victims were pregnant or recently pregnant. According to CDC, 
17 states, New York City, and Puerto Rico collect data related to 
pregnancy status on their death certificates, but the data collected 
are not comparable. Included in these data are victims who may not 
have been pregnant at the time of death but had been "recently" 
pregnant; in addition, states' criteria for recent pregnancy ranged 
from 42 days to 1 year after birth. (See app. Ill for a list of the 
questions on pregnancy status that states include on their death 
certificates.) 

The ability to identify pregnant homicide victims from death 
certificates is limited. While there are questions on some states' 
death certificates regarding pregnancy status, officials in the four 
states we contacted (Illinois, Maryland, New Mexico, and New York) 
told us that these data are incomplete and may understate the number 
of pregnant homicide victims. For example, if the pregnancy item on 
the death certificate is left blank, there is no way to easily 
determine whether an autopsy, if conducted, included a test or 
examination for pregnancy. Moreover, researchers have reported that 
physicians completing death certificates after a pregnant woman's 
death failed to report that the woman was pregnant or had a recent 
pregnancy in at least 50 percent of the cases.[Footnote 13] 

To address these limitations, all four states we contacted are making 
efforts to compare death certificate data with other datasets and 
records-—such as medical examiners' reports-—to identify pregnant or 
recently pregnant homicide victims. They told us that they are 
reviewing the data in order to determine if there is something they 
can do to prevent violent deaths of pregnant women or help women who 
are victimized. For example, the Maryland medical examiner's office 
conducted a study of the deaths of females aged 10 to 50 to determine 
if these women were pregnant when they died. Several sources of data—-
death certificates, medical examiners' reports, and recent live birth 
and fetal death records-—from a 6-year period were linked. Of the 247 
women who were identified as pregnant or recently pregnant, 27 percent 
were identified through examining cause of death information on death 
certificates. The remaining 73 percent were identified by matching the 
woman's death certificate with recent birth and fetal death records 
and by reviewing data from medical examiners' records, such as autopsy 
reports or police records. Similarly, New York officials determined 
through dataset links (death certificates, fetal death records, recent 
birth certificates, and hospital discharge records) that, in 1997, 9 
of 174 female homicide victims aged 10 to 54 were pregnant or recently 
pregnant at the time of death, rather than the 1 of 174 that death 
certificate data alone would have indicated. Officials from New York 
and Maryland told us these efforts to link datasets are dependent on 
records being computerized. Some state officials also told us they did 
not have the resources to conduct these analyses on a continuing basis. 

There are two federal initiatives under development that propose to 
collect data on the number of homicides of pregnant women. CDC is 
proposing a revision of the U.S. standard certificate of death used 
for the National Vital Statistics System to include five categories 
related to pregnancy status. (See figure 1.) Each state has the option 
of adopting the U.S. standard certificate for its death certificate or 
excluding or adding data elements. If the revision is approved, CDC 
expects several states to implement it in 2003, with an increasing 
number using it each year. 

Figure 1: Pregnancy Status Categories on Proposed U.S. Standard Death 
Certificate Revision: 

[Refer to PDF for image: illustration] 

If female:  

* Not pregnant within past year. 

* Pregnant at time of death. 

* Not pregnant, but pregnant within 42 days of death. 

* Not pregnant, but pregnant 43 days to 1 year before death. 

* Unknown if pregnant within the past year. 

Source: CDC. 

[End of figure] 

CDC is also beginning to implement the National Violent Death 
Reporting System (NVDRS), which, as currently envisioned, would 
collect data that could determine the number of pregnant homicide 
victims. CDC plans to collect data from a variety of state and local 
government databases on deaths resulting from homicide and suicide. 
Like the Maryland and New York efforts, NVDRS would link several 
databases, such as death and medical examiners' records, to identify 
pregnant homicide victims. According to CDC, implementation of NVDRS 
depends on future funding; full implementation would take at least 5 
years. The estimated federal cost of this system is $10 million in 
start-up costs and $20 million in annual operating costs; these 
estimates primarily consist of expenditures for providing technical 
assistance to the states and funding for state personnel to collect 
the data. 

Multiple Strategies Designed to Prevent Violence, But Effect Is 
Unknown: 

Violence prevention strategies for both pregnant and nonpregnant women 
include measures to prevent initial incidents of violence, such as 
educating women about warning signs of abuse, and intervention 
activities that identify and respond to violence after it has 
occurred. Typically, the initial component of an intervention is 
screening, or asking women about their experiences with violence. Many 
health care organizations and providers recommend routine screening 
for intimate partner violence. Studies have found, however, that fewer 
than half of physicians routinely screen for violence during prenatal 
visits. Reasons for physicians' reluctance to screen include lack of 
training on how to screen and how to respond if a woman discloses 
violence. Violence prevention strategies also include criminal justice 
measures, which focus on apprehending, sentencing, incarcerating, and 
rehabilitating batterers. Little information is available on the 
effectiveness of violence prevention strategies and programs. 
Researchers have reported the need for evaluations of the 
effectiveness of screening protocols and batterer intervention 
programs. 

Violence Prevention Programs Use Health and Criminal Justice 
Strategies: 

Measures to prevent violence against pregnant women are similar to 
those to prevent violence against all women. Public health violence 
prevention programs can include primary prevention measures to keep 
violence from occurring in the first place and interventions that ask 
women about their experiences with violence and respond if violence 
has occurred. Criminal justice strategies to prevent violence against 
women focus on apprehending, sentencing, incarcerating, and 
rehabilitating batterers. 

Efforts to prevent initial incidents of violence concentrate on 
attitudes and behaviors that result in violence against women. These 
efforts include educating children, male and female, about ways to 
handle conflict and anger without violence and social norms about 
violence, such as attitudes about the acceptability of violence toward 
women. They also include training parents, police officers, and other 
community officials to be resources for youth seeking assistance about 
teenage dating violence. Primary prevention efforts also have been 
targeted to pregnant women. For example, the Domestic Violence During 
Pregnancy Prevention Program in Saginaw, Michigan, provided 15-minute 
counseling sessions to pregnant women who reported that they had not 
experienced violence.[Footnote 14] Women were educated about intimate 
partner violence and given tools and information to help prevent abuse 
in their lives, including information on behaviors typical of abusive 
men, warning signs of abuse, and community resources. 

Interventions to deal with violence that has occurred are designed to 
identify victims and to prevent additional violence through such 
actions as providing an assessment of danger, developing a safety 
plan, and providing information about and referral to community 
resources. For example, HRSA has funded a demonstration program to 
develop or enhance systems that identify pregnant women experiencing 
intimate partner violence and provide appropriate information and 
links to services. The HRSA program funds four projects; each project 
is funded at $150,000 a year for 3 years.[Footnote 15] 

Screening for the presence of violence is generally the initial 
component of intervention efforts to prevent additional violence 
against pregnant women. Many experts view the period of pregnancy as a 
unique opportunity for intervention. Pregnant women who receive 
prenatal care may have frequent contact with providers, which allows 
for the development of relationships that may facilitate disclosure of 
violence. For example, the American College of Obstetricians and 
Gynecologists (ACOG) recommends that physicians screen all patients 
for intimate partner violence and that screening for pregnant women 
occur at several times over the course of their pregnancies. Some 
women do not disclose abuse the first time they are asked, or abuse 
may begin later in pregnancy. Some of the barriers to women's 
disclosure of violence are fear of escalating violence, feelings of 
shame and embarrassment, concern about confidentiality, fear of police 
involvement, and denial of abuse. In addition, some health care 
officials told us that the period of pregnancy may be a difficult time 
for a woman to leave or take action against the abuser because of 
financial concerns and pressures to provide the child with a father. 

Studies have found that fewer than half of physicians routinely screen 
women for violence during pregnancy. For example, a survey of ACOG 
fellows reported that 39 percent of respondents routinely screened for 
violence at the first prenatal visit.[Footnote 16] The study found 
that screening was more likely to occur when the obstetrician-
gynecologist suspected a patient was being abused. Another study that 
surveyed primary care physicians who provide prenatal care found that 
only 17 percent of respondents routinely screened at the first 
prenatal visit and 5 percent at follow-up visits.[Footnote 17] Across 
the 15 states with PRAMS data for 1998, from 25 percent to 40 percent 
of women reported that a physician or other health care provider 
talked to them about intimate partner violence during any of their 
prenatal care visits. 

CDC and providers of prevention services have reported that reasons 
for physicians' reluctance to screen women for violence include lack 
of time and resources, personal discomfort about discussing the topic, 
concern about offending patients, belief that asking invades family 
privacy, and frustration with patients who are not ready to leave or 
who return to their abusers. Lack of training and education on how to 
screen for intimate partner violence and lack of knowledge about what 
to do if a woman reports experiencing intimate partner violence have 
also been cited as barriers to physician screening. In its report on 
family violence, the Institute of Medicine stated that health 
professionals' training and education about family violence are 
inadequate and recommended that the Secretary of HHS establish 
education and research centers to develop training programs that 
prepare health professionals to respond to family violence. 

Criminal justice approaches to preventing violence against women 
include apprehending and sanctioning the batterer, preventing further 
contact between the abuser and the victim, and connecting the victim 
to community services. In addition, batterer intervention programs, 
which have existed for over 20 years as a criminal justice 
intervention, are often used as a component of pretrial or diversion 
programs or as part of sentencing. Batterer programs can include 
classes or treatment groups, evaluation, individual counseling, or 
case management; their goals are rehabilitation and behavioral change. 

To assist communities, policymakers, and individuals in combating 
violence against women, the National Advisory Council on Violence 
Against Women and VAWO developed a Web-based resource for instruction 
and guidance.[Footnote 18] These guidelines include recommendations 
for strengthening prevention efforts and improving services and 
advocacy for victims. For example, the guidelines recommend that 
communities increase the cultural and linguistic competence of their 
sexual assault, intimate partner violence, and stalking programs by 
recruiting and hiring staff, volunteers, and board members who reflect 
the composition of the community the program serves. The guidelines 
also recommend that all health and mental health care professional 
school and continuing education curricula include information on the 
prevention, detection, and treatment of sexual assault and intimate 
partner violence. 

Little Information Is Available on the Effectiveness of Violence 
Prevention Programs: 

Researchers have reported that little information is available on the 
effectiveness of strategies to prevent and reduce violence against 
women. For example, many health care organizations and providers 
advocate routine screening of pregnant women for intimate partner 
violence, but questions have been raised about the effectiveness of 
screening, the most effective way to conduct screening, and the 
optimal times for conducting screening. In addition, limited 
information is available on the impact of screening on women and their 
children. 

A CDC official told us that CDC has not issued guidelines or 
recommendations related to routine screening for violence in health 
care settings, primarily due to the lack of scientific evidence about 
the effectiveness of screening. CDC recently funded a cooperative 
agreement to measure the effectiveness of an intimate partner violence 
intervention that includes evaluation of a screening protocol and 
computerized screening.[Footnote 19] The results of the study are 
expected to provide data on the array of outcomes that need to be 
considered in implementing intervention programs to decrease intimate 
partner violence. CDC officials told us that additional studies are 
necessary to evaluate screening and intervention strategies and that 
CDC is in the process of identifying additional study topics and 
designs that could complement this effort. 

CDC and other researchers on violence against women and providers of 
prevention services have identified several other areas in which 
research could be fruitful. For example, they have reported the need 
to: 

* develop information on the most effective ways to promote women's 
safety after screening; 

* develop and evaluate the effectiveness of programs that coordinate 
community resources from the medical, social services, law 
enforcement, judicial, and legal systems; and; 

* develop and evaluate the effectiveness of prevention strategies that 
incorporate cultural perspectives in serving ethnic and immigrant 
populations. 

An example of an effort to conduct such research is HRSA's program to 
improve interventions for pregnant women experiencing violence; 
however, the projects' evaluation components are small and, according 
to HHS, their results may not be generalizable to the nation. Each 
funded project will evaluate whether its intervention was effective in 
improving rates of screening, assessment, and referral or links to 
community services; the projects may also assess the impact of the 
intervention on women's behaviors. For example, the Comprehensive 
Services program in Baltimore is assessing whether the project was 
effective in linking families to needed services and whether women 
report improvement in their physical or psychosocial status after the 
intervention. The Systems for Pregnancy Education and Awareness of 
Safety in New York is evaluating whether the project increases the 
number of women who disclose violence and receive services and 
referrals to community services, such as shelters. The Perinatal 
Partnership Against Domestic Violence in Seattle is evaluating the 
effectiveness of screening protocols and interventions that are 
tailored to the culture and values of women who are Asian and Pacific 
Islanders. 

Researchers have also reported that there is little evaluative 
information on the effectiveness of violence prevention programs for 
batterers. A VAWO-funded study of the effectiveness of batterer 
programs concluded that they have modest effects on violence 
prevention when compared with traditional probationary practices and 
that there is little evidence to support the effectiveness of one 
batterer program over another in reducing recidivism.[Footnote 20] The 
study concluded, however, that batterer programs are a small but 
critical element in an overall violence prevention effort that 
includes education, arrest, prosecution, probation, and victim 
services. The study authors advocated experimenting with different 
program approaches and performing outcome evaluations of batterer 
programs. 

Concluding Observations: 

The magnitude of the problem of violence against pregnant women is 
unknown. Current collaborative efforts by federal and state 
governments to gather and analyze more complete and comparable data 
could improve policymakers' knowledge of the extent of this violence 
and guide future research and resource allocation. These efforts can 
also help in setting priorities for prevention strategies. Continuing 
evaluation of prevention strategies and programs could help identify 
successful approaches for reducing violence against women. 

Agency Comments: 

We provided a draft of this report to Justice and HHS for comment. 
Justice informed us that it did not have any comments. HHS agreed with 
our finding that limited information is available regarding violence 
against pregnant women. HHS also noted reasons why the data are 
incomplete, such as the difficulty of collecting data from a 
representative sample of pregnant victims because they are such a 
small percentage of the U.S. population. Other reasons HHS cited are 
legal and ethical issues in conducting research on this population, 
such as maintaining privacy and confidentiality. HHS commented that 
several states are conducting mortality reviews to better understand 
pregnancy-related deaths and their underlying causes. 

HHS raised several issues that it considers important regarding 
violence against women, such as the need to evaluate factors 
correlated with violence against women, and identified additional 
efforts within the department that focus on intimate partner violence. 
We recognize that there are many issues and efforts related to 
violence against women; however, our focus was on violence against 
pregnant women, and therefore much of our discussion relates to this 
population. HHS noted that although HRSA's demonstration program to 
improve interventions for pregnant women experiencing violence will 
result in new qualitative information, the evaluation component is 
small and the findings would likely be limited. We modified our 
discussion of this program to indicate that it is a small 
demonstration program and its results may not be generalizable to the 
nation. In response to HHS's comments, we added a description of 
another demonstration program focused on violence against pregnant 
women that HRSA plans to initiate in June 2002. HHS also provided 
technical comments, which we incorporated where appropriate. (HHS's 
comments are reprinted in appendix IV.) 

As arranged with your office, unless you publicly announce its 
contents earlier, we plan no further distribution of this report until 
30 days after its issue date. We will then send copies to the 
Secretary of Health and Human Services; the Attorney General; the 
Administrator of the Health Resources and Services Administration; the 
Directors of the Centers for Disease Control and Prevention, National 
Institutes of Health, Office of Justice Programs, and Federal Bureau 
of Investigation; appropriate congressional committees; and others who 
are interested. We will also make copies available to others on 
request. 

If you or your staff have any questions, please contact me at (202) 
512-8777 or Janet Heinrich, Director, Health Care—Public Health 
Issues, at (202) 512-7119. Additional GAO contacts and the names of 
other staff members who made contributions to this report are listed 
in appendix V. 

Sincerely yours, 

Signed by: 

Paul L. Jones: 
Director, Tax Administration and Justice: 

[End of section] 

Appendix I: Scope and Methodology: 

To do our work, we interviewed and obtained information from officials 
at the Department of Health and Human Services' Centers for Disease 
Control and Prevention (CDC), Health Resources and Services 
Administration (HRSA), and National Institutes of Health, and the 
Department of Justice's Office of Justice Programs (OJP) and Federal 
Bureau of Investigation (FBI). We also interviewed representatives of 
and obtained information from the American College of Obstetricians 
and Gynecologists, Institute of Medicine, Family Violence Prevention 
Fund, National Coalition Against Domestic Violence, and National 
Association of Medical Examiners; several state domestic violence 
coalitions; and researchers. 

To determine the availability of information on the prevalence and 
risk of violence against pregnant women, we reviewed literature on the 
prevalence and risk of violence to women during pregnancy. We 
identified 11 studies published since 1998 that contained prevalence 
estimates and assessed their methodologies to ensure the 
appropriateness of the data collection and analysis methods and the 
conclusions. We also interviewed CDC officials and reviewed data 
collected through CDC's Pregnancy Risk Assessment Monitoring System 
(PRAMS). 

To determine the availability of data on the number of pregnant women 
who are victims of homicide in the United States, we interviewed 
officials and collected and analyzed homicide statistics and reports 
from CDC, the FBI, and OJP's Bureau of Justice Statistics. We also 
interviewed officials from state departments of health and vital 
statistics in Illinois, Maryland, New Mexico, and New York to 
determine how they collect and use data on pregnant homicide victims. 
We selected these states because, in addition to collecting pregnancy 
data on their state death certificates, they are active in collecting 
and analyzing information from various sources to study maternal 
health issues. The states were not intended to be representative of 
all states. We also interviewed and obtained information from CDC and 
Justice officials to identify federal initiatives that are under way 
to improve the availability of information on homicides of pregnant 
women. 

To identify strategies and programs to prevent violence against 
pregnant women, we gathered information through a literature review 
and interviews with and information collected from researchers and 
officials from federal agencies, health care associations, and 
advocacy groups. We reviewed a HRSA-funded program (with projects 
located in Illinois, Maryland, New York, and Washington) and two other 
programs (located in Michigan and Pennsylvania) because they focused 
specifically on violence against pregnant women and served varied 
populations, including adolescents, diverse ethnic groups, and women 
with substance abuse problems. 

We conducted our work from July 2001 through April 2002 in accordance 
with generally accepted government auditing standards. 

[End of section] 

Appendix II: Description of the Pregnancy Risk Assessment Monitoring 
System: 

CDC developed PRAMS, a population-based survey of women whose 
pregnancies resulted in live births. CDC awards grants to states to 
help them collect information on women's experiences and behaviors 
before, during, and immediately following pregnancy. CDC funded about 
$6.2 million for PRAMS in fiscal year 2001; grant awards to states 
ranged from $100,000 to $150,000. CDC's funding for PRAMS also 
includes costs for CDC staff and contractors to provide technical 
support to the states. 

States participating in PRAMS use a consistent methodology to collect 
data. Each state selects a stratified sample of new mothers every 
month from eligible birth certificates and then collects data through 
mailings and follow-up telephone calls to nonrespondents. A birth 
certificate is eligible for the PRAMS sample if the mother was a 
resident of the state. For 1998, the most recent year for which CDC 
has reported comprehensive data for PRAMS, states used a standardized 
questionnaire that asked women if their husbands or partners 
physically abused them during their most recent pregnancy. PRAMS 
defined physical abuse as pushing, hitting, slapping, kicking, or any 
other way of physically hurting someone.[Footnote 21] Table 1 lists 
1998 PRAMS estimates of the prevalence of intimate partner violence 
during pregnancy. 

Table 1: PRAMS Estimates of the Prevalence of Physical Abuse by 
Husband or Partner during Pregnancy, 1998: 

State: Alabama; 
Percentage[A]: 3.8%. 

State: Alaska; 
Percentage[A]: 3.8%. 

State: Arkansas; 
Percentage[A]: 5.5%. 

State: Colorado; 
Percentage[A]: 2.8%. 

State: Florida; 
Percentage[A]: 4.1%. 

State: Illinois; 
Percentage[A]: 4.1%. 

State: Louisiana; 
Percentage[A]: 5.2%. 

State: Maine; 
Percentage[A]: 2.5%. 

State: New Mexico[B]; 
Percentage[A]: 6.6%. 

State: New York[C]; 
Percentage[A]: 2.4%. 

State: North Carolina; 
Percentage[A]: 4.2%. 

State: Oklahoma; 
Percentage[A]: 5.1%. 

State: South Carolina; 
Percentage[A]: 3.9%. 

State: Washington; 
Percentage[A]: 3.5%. 

State: West Virginia; 
Percentage[A]: 4.7%. 

Note: PRAMS includes data only for women whose pregnancies resulted in 
live births. 

[A] This column represents the proportion of pregnant women who 
reported physical abuse (i.e., pushing, hitting, slapping, kicking, or 
any other way of physically hurting someone). 

[B] Data represent births from July 1997 through December 1998. 

[C] Data do not include New York City. 

Source: L.E. Lipscomb and others, PRAMS 1998 Surveillance Report 
(Atlanta, Ga.: Division of Reproductive Health, National Center for 
Chronic Disease Prevention and Health Promotion, Centers for Disease 
Control and Prevention, 2000). 

[End of table] 

[End of section] 

Appendix III: Pregnancy Status Questions on States' Death Certificates: 

State: Alabama; 
Question: Was there a pregnancy in last 90 days or 42 days? 

State: Florida; 
Question: If female, was there a pregnancy in the past 3 months? 

State: Georgia; 
Question: If female, indicate if pregnant or birth occurred within 90 
days of death. 

State: Illinois; 
Question: If female, was there a pregnancy in the past 3 months? 

State: Indiana; 
Question: Was decedent pregnant or 90 days postpartum? 

State: Iowa; 
Question: If female, was there a pregnancy in the past 12 months? 

State: Louisiana; 
Question: If deceased was female 10-49, was she pregnant in the last 90
days? 

State: Maine; 
Question: Indicate if the decedent was pregnant or less than 90 days
postpartum at time of death. 

State: Maryland; 
Question: If female, was decedent pregnant in the past 12 months? 

State: Missouri; 
Question: If deceased was female 10-49, was she pregnant in the last 90
days? 

State: Nebraska; 
Question: If female, was there a pregnancy in the past 3 months? 

State: New Jersey; 
Question: If female, was she pregnant at death or any time 90 days 
prior to death? 

State: New Mexico; 
Question: Was decedent pregnant within last 6 weeks? 

State: New York; 
Question: If female, was decedent pregnant in last 6 months? 

State: New York City[A]; 
Question: If female under 54, pregnancy in last 12 months? 

State: North Dakota; 
Question: Was deceased pregnant within 18 months of death? 

State: Puerto Rico; 
Question: If female, was deceased pregnant? 

State: Texas; 
Question: Was decedent pregnant at time of death; within last 12 
months? 

State: Virginia; 
Question: If female, was there a pregnancy in last 3 months? 

Note: According to CDC, these are the only states that include 
questions on pregnancy status on their death certificates. The term 
"states" includes New York City and Puerto Rico. 

[A] According to New York state officials, New York City uses a 
different death certificate from the rest of the state. The New York 
City death certificate is used for the five boroughs of the city: 
Manhattan, Brooklyn, Queens, the Bronx, and Staten Island. 

Source: CDC. 

[End of table] 

Appendix IV: Comments from the Department of Health and Human Services: 

Department Of Health & Human Services: 
Office of Inspector General: 
Washington, D.C. 20201: 

May 3, 2002: 

Mr. Paul L. Jones: 
Director, Tax Administration and Justice: 
United States General Accounting Office: 
Washington, D.C. 20548: 

Dear Mr. Jones: 

Enclosed are the Department's comments on your draft report, "Violence 
Against Women: Data on Pregnant Victims and Effectiveness of 
Prevention Strategies Are Limited." The comments represent the 
tentative position of the Department and are subject to reevaluation 
when the final version of this report is received. 

The Department also provided technical comments directly to your staff.
The Department appreciates the opportunity to comment on this draft 
report before its publication. 

Sincerely, 

Signed by: 

Michael Mangano, for: 

Janet Rehnquist: 
Inspector General: 

Enclosure: 

[The Office of Inspector General (OIG) is transmitting the 
Department's response to this draft report in our capacity as the 
Department's designated focal point and coordinator for General 
Accounting Office reports. The OIG has not conducted an independent 
assessment of these comments and therefore expresses no opinion on 
them.] 

[End of letter] 

Department of Health and Human Services (DHHS) Comments to the General 
Accounting Office Draft Report: Violence Against Women: Data on 
Pregnant Victims and Effectiveness of Prevention Strategies Are 
Limited (GAO-02-530): 

Background: 

Information on the prevalence of violence against pregnant women 
appears to be lacking, in part due to the difficulty of collecting 
data from a reliable national sample. Current data on domestic 
violence and violence against women indicates that there is an urgent 
need to develop mechanisms to collect and assess data on this topic. 
The report does a good job of outlining the little information that is 
available regarding violence against pregnant women. It also cites 
that the literature is inconclusive about whether women are at 
increased risk for violence during pregnancy. The Department agrees 
that the data are very limited in this area, however we believe there 
is more detail than was reported. The focus of the review was on 
pregnant victims of violence and, appropriately so, data were 
presented on violence against women in general. The report concludes 
appropriately that the data are incomplete and not comparable across 
sources, making it impossible to evaluate the extent of the problem. 

The difficulty of locating a representative sample of pregnant victims 
of violence, and the legal and ethical issues in conducting such 
research are some of the challenges that must be overcome in improving 
data on this important issue. 

General Comments: 

It would strengthen the report to include more violence information on 
women of childbearing age from the Behavioral Risk Factor Surveillance 
System (BRFSS), and similar Centers for Disease Control and Prevention 
(CDC) studies such as the National Survey of Family Growth (NSFG). The 
2000 BRFSS does not, unfortunately ask the standard domestic violence 
questions that are included in the Youth Risk Behavior Surveillance 
System (YRBSS). It does, however ask about stress/depression and 
substance use including smoking and HIV, which are correlated with 
domestic violence. The NSFG has collected and published data on non-
voluntary intercourse from a national sample of women [hyperlink, 
http://www.cdc.gov/nchs/nsfg.htm]. 

The report would be strengthened by including discussions of the 
potential role of other government agencies; for example, the Agency 
for Healthcare Research and Quality's potential contribution to 
developing and or disseminating guidelines for screening and 
interventions for women at risk of domestic violence to be used in 
general medical settings; and by discussions of referral systems and 
models of care for women who require more intensive interventions 
(e.g. in specialized mental health settings). The National Institutes 
of Health (NIH) has funded substantial research on risk factors for 
posttraumatic stress disorder, a common consequence of violence and 
trauma. The report would be strengthened by discussion of how this 
research could be used to improve screening efforts and intervention 
development. 

It would be helpful to include more discussion of the need to evaluate 
the behavioral health (e.g. depression, anxiety and substance abuse) 
correlates of violence against women. The DHHS Substance Abuse and 
Mental Health Services Administration (SAMHSA) study, Women and 
Violence, is the first major national study designed to study 
interrelationships between violence and co-occurring disorders in 
adult females over the age of eighteen (18). It is a major effort to 
integrate trauma treatment into mental health and substance abuse 
services with an array of supportive services. 

Additional discussion is needed for methods of assessing the level of 
risk to the abused women, which would seem important in terms of 
identifying appropriate referral and services. These could range from 
counseling to criminal justice interventions. We also suggest a 
discussion of cultural issues relating to family violence (e.g. in 
some cultures women may be accompanied to visits by family members who 
may be complicit in the abuse). It is important to note that although 
prevention efforts such as screening should reach all women, they can 
be especially helpful when targeted to those at highest risk (i.e., 
special populations) and can be made available through other services 
provided to these pregnant women (such as concurrent drug abuse 
treatment, HIV treatment service, etc). 

The Executive Summary ends on a very positive and hopeful note about 
prevention projects the Department's Health Resources and Services 
Administration is currently funding. The Maternal Child Health Bureau 
(MCHB) is concerned that the size of the demonstration grant and the 
magnitude of the projects results may be overstated. These are the 
first projects to really explore systems development to screen and 
intervene in perinatal violence. They are geographically and 
culturally diverse, and there will be unique and novel qualitative 
information gained from them. However, these projects are only funded 
at $150,000/year/grant for three years, and the results may not be 
generalizable to the U.S. population. These grants have small 
evaluation components. However, they are not necessarily consistent 
across projects. Evaluation findings are likely to be limited. 

MCHB has another demonstration grant program in FY 2002, entitled: 
Developing a System of Care to Address Family Violence During or 
Around the Time of Pregnancy. MCHB suggests that the planned scope of 
this effort be described to ensure that the Congress receives a full 
disclosure of what can be learned from this initiative. Awards to four 
(4) new communities targeting family violence are expected to be made 
within the month. The effective date is June 1, 2002, most likely 
before the release of this report, consequently it may be appropriate 
to mention a little more about each of the four projects if GAO 
chooses. One important comparison between the FY 2000 domestic 
violence grants and the FY 2002 family violence grants is that the new
competition has expanded its scope to address the epidemiological 
cycle of violence. The primary focus remains the woman experiencing 
violence but projects will also link to child abuse, elder abuse, and 
perpetrator rehabilitation programs. The new projects are also Healthy 
Start grantees with experience in community-based activities to 
improve perinatal outcomes. It would strengthen the data section or 
the discussion of these projects on page 23 to include some of their 
needs assessment information. 

The report does not mention work being done by States in Title V 
programs. As reported in the Title V Information System [hyperlink, 
http://www.mchdata.net] 12 States (Alaska, California, Florida, 
Hawaii, Louisiana, Massachusetts, Montana, Nevada, Ohio, Oregon, 
Texas, and Washington) have optional State-negotiated performance 
measures that target domestic violence by monitoring physical abuse, 
rape or reported incidents of assault. However, States were limited in 
the number of state-specific measures they could add, so this 
shouldn't necessarily be taken to mean that violence is a low priority 
for MCH in other States. 

With regard to the knowledge of prevalence of violence during 
pregnancy, there are approximately four (4) million births in the U.S. 
per year (only 1.5 percent of the United States' 270 million people). 
Currently pregnant women are a small percentage of the total U.S.
population, which makes it difficult and expensive to collect 
representative data on them. That is why the studies that have been 
done are mostly on non-representative, convenience samples. 
Additionally, collecting data on violence against women is an 
extremely sensitive subject that involves difficult legal and ethical 
issues for interviewers, including issues pertaining to reporting 
abuse to state or local authorities; obtaining informed consent; and 
maintaining privacy and confidentiality. Special training and special 
qualifications may be required to administer interviews on this 
subject. Thus such studies may be more difficult and more costly to 
conduct than studies of less sensitive topics. 

The report also could mention at the end of page 14 that several 
states currently are also conducting maternal mortality reviews, which 
try to better understand pregnancy-related deaths and the underlying 
causes, with the intent of preventing future pregnancy-related deaths. 
Until recently, most maternal mortality review committees were 
primarily hospital-based and not interdisciplinary committees 
conducted by states. The Centers for Disease Control and Prevention 
(CDC) and MCHB have been collaborating over the past several years to 
encourage states to conduct maternal mortality reviews that are 
interdisciplinary and include all available data. In addition, a few 
states are now also conducting mortality reviews that only focus on 
deaths that relate to domestic violence. These reviews have the 
potential to help local public authorities to establish the underlying 
causes of maternal and infant deaths - some of which are attributable 
to domestic and family violence. 

The report mentions the American College of Obstetricians and 
Gynecologists (ACOG) screening recommendations. It is important to 
also mention the Family Violence Prevention Fund (FVPF) and the United 
States Preventive Services Task Force (USPSTF) prenatal guidelines. 
Each recommends periodic screening. The weakness in these guidelines 
is that they do not differentiate between screening and a more in 
depth assessment. Since many women are hesitant to disclose that they 
are experiencing violence, the combination of frequent screening and a 
thorough assessment are important. Further, based on what our projects 
are validating, intervention services are lacking in communities for 
pregnant women experiencing violence. Often times, the services are 
not coordinated which leads to decreased access and utilization and 
increased risk to safety. As the report states, providers are 
reluctant to screen due to lack of knowledge about the screening 
process and what to do with a positive finding. We have also received 
reports that providers are also reluctant to screen because they are 
unsure of what to document and are concerned that screening would 
result in uncompensated time away from work to appear in court. 

The report should also include the work the Department's HRSA Office 
of Minority Health is doing on domestic violence with their training 
videos and the work on community and migrant health centers through 
the Bureau of Primary Health Care. The Department's HRSA Bureau of 
Primary Care Office on Women's and Minority Health recently received 
clearance for the publication, Healing Shattered Lives: Assessment of 
Selected Domestic Violence Programs in Primary Health Care Settings. 
The report profiles promising clinical programs in community based 
primary health service sites. The report will be released in FY 2002. 

The Department appreciates the opportunity to participate in this 
review and we look forward to working with the General Accounting 
Office and other departments on developing and implementing tools that 
would collect data on the above subject. Such information can 
potentially affect the management of certain state and local programs. 
Interventions can be redefined to better serve a silent population. 

Technical comments were provided under separate cover. 

[End of section] 

Appendix V: GAO Contacts and Staff Acknowledgments: 

GAO Contacts: 

Weldon McPhail, (202) 512-8644. 
Helene F. Toiv, (202) 512-7162. 

Staff Acknowledgments: 

In addition to those named above, contributors to this report were 
Janina Austin, Nancy Kawahara, Emily Gamble Gardiner, Geoffrey 
Hamilton, Anthony Hill, Hiroshi Ishikawa, Alice London, Behn Miller, 
and Sara-Ann Moessbauer. 

[End of section] 

Footnotes: 

[1] U.S. Department of Health and Human Services, Healthy People 2010: 
Understanding and Improving Health, 2nd ed. (Washington, D.C.: U.S. 
Government Printing Office, November 2000). 

[2] VAWA was enacted in 1994 as Title IV of the Violent Crime Control 
and Law Enforcement Act of 1994, P.L. No. 103-322, 108 Stat. 1796, 
1945. In 2000, VAWA was reauthorized and amended-—adding several new 
programs. See Victims of Trafficking and Violence Protection Act of 
2000, P.L. No. 106-386, 114 Stat. 1464, 1491. 

[3] Patricia Tjaden and Nancy Thoennes, Prevalence, Incidence, and 
Consequences of Violence Against Women: Findings From the National 
Violence Against Women Survey, NCJ 172837 (Washington, D.C.: U.S. 
Department of Justice, November 1998). 

[4] VAWA funds programs in both Justice and HHS. Justice's fiscal year 
2002 appropriation for VAWA programs was $390.6 million. HHS's fiscal 
year 2002 appropriation for VAWA programs was $176.7 million for 
battered women's shelters, a domestic violence hotline, rape 
prevention and education, and community programs on intimate partner 
violence. 

[5] Callie Marie Rennison, Intimate Partner Violence and Age of 
Victim, 1993-99, Bureau of Justice Statistics Special Report, NCJ 
187635 (Washington, D.C., U.S. Department of Justice, October 2001). 

[6] The most recent year for which CDC has reported comprehensive data 
for PRAMS is 1998. CDC reported data for those 15 participating states 
that had fully implemented PRAMS data collection procedures and 
achieved CDC's required response rate of at least 70 percent. One 
additional state participated in PRAMS but did not meet these criteria. 

[7] CDC reported that, in 1997, 63 percent of pregnancies resulted in 
live births. 

[8] Julie A. Gazmararian and others, "Prevalence of Violence Against 
Pregnant Women," JAMA 275, no. 24 (1996): 1915-1920. 

[9] Melissa Moore, "Reproductive Health and Intimate Partner 
Violence," Family Planning Perspectives 31, no. 6 (1999): 302-306, 312. 

[10] Sandra L. Martin and others, "Physical Abuse of Women Before, 
During, and After Pregnancy," JAMA 285, no. 12 (2001): 1581-1584. 

[11] For example, see Mary M. Goodwin and others, "Pregnancy 
Intendedness and Physical Abuse Around the Time of Pregnancy: Findings 
from the Pregnancy Risk Assessment Monitoring System, 1996-1997," 
Maternal and Child Health Journal 4, no. 2 (2000): 85-92; and Vilma E. 
Cokkinides and others, "Physical Violence During Pregnancy: Maternal 
Complications and Birth Outcomes," Obstetrics & Gynecology 93, no. 5 
(1999): 661-666. 

[12] Family violence includes intimate partner violence, child abuse 
and neglect, and elder abuse. Institute of Medicine, Confronting 
Chronic Neglect: The Education and Training of Health Professionals on 
Family Violence (Washington, D.C.: 2001). 

[13] Isabelle L. Horon and Diana Cheng, "Enhanced Surveillance for 
Pregnancy-Associated Mortality—Maryland, 1993-1998," Journal of the 
American Medical Association 285, no. 11 (2001): 1455-1459. 

[14] This program is a component of the Saginaw Fetal-Infant Mortality 
Review Program. 

[15] The projects are the Comprehensive Services for Pregnant Women 
Experiencing Substance Abuse and Violence in Baltimore, Maryland; 
Systems for Pregnancy Education and Awareness of Safety in New York, 
New York; Improving Systems of Care for Pregnant Women Experiencing 
Domestic Violence in St. Clair County, Illinois; and Perinatal 
Partnership Against Domestic Violence: Improving Systems of Care for 
Pregnant/Post Partum Women in the Asian and Pacific Islander Community 
in Seattle, Washington. HRSA is planning to initiate another 
demonstration program in June 2002 to address family violence during 
or around the period of pregnancy. The primary focus of the program is 
women experiencing violence, but its projects will also link to child 
abuse, elder abuse, and perpetrator rehabilitation programs. 

[16] Deborah L. Horan and others, "Domestic Violence Screening 
Practices of Obstetrician-Gynecologists," Obstetrics & Gynecology 92, 
no. 5 (1998): 785-789. 

[17] Linda Chamberlain and Katherine A. Perham-Hester, "Physicians' 
Screening Practices for Female Partner Abuse During Prenatal Visits," 
Maternal and Child Health Journal 4, no. 2 (2000): 141-148. 

[18] Nationa1 Advisory Council on Violence Against Women and the 
Violence Against Women Office, Toolkit to End Violence Against Women 
(Washington, D.C.: U.S. Department of Justice, November 2001). 
[hyperlink, http://toolkit.ncjrs.org] (downloaded on February 12, 
2002). 

[19] The cooperative agreement is between CDC, Johns Hopkins 
University, and the State University of New York at Albany. 

[20] Larry Bennett and Oliver Williams, Controversies and Recent 
Studies of Batterer Intervention Program Effectiveness, Grant number 
98-WT-VX-K001 (Washington, D.C.: U.S. Department of Justice, 2001). 

[21] Some states have also added questions on verbal and emotional 
abuse. 

[End of section] 

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